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Barra ME, Forman R, Long-Fazio B, Merkler AE, Gurol ME, Izzy S, Sharma R. Optimal Timing for Resumption of Anticoagulation After Intracranial Hemorrhage in Patients With Mechanical Heart Valves. J Am Heart Assoc 2024; 13:e032094. [PMID: 38761076 DOI: 10.1161/jaha.123.032094] [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: 11/23/2023] [Accepted: 04/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Anticoagulation in patients with intracranial hemorrhage (ICH) and mechanical heart valves is often held for risk of ICH expansion; however, there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation remains uncertain. METHODS AND RESULTS We retrospectively studied patients with ICH and mechanical heart valves from 2000 to 2018. The primary outcome was a composite end point of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of reinitiation of anticoagulation classified as early (resumed up to 7 days after ICH), late (≥7 and up to 30 days after ICH), and never if not resumed or resumed after 30 days post-ICH. We included 184 patients with ICH and mechanical heart valves (65 anticoagulated early, 100 late, 19 not resumed by day 30 post-ICH). Twelve patients had AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation was 12.7 days. Composite outcomes occurred in 12 patients resumed early (18.5%), 14 resumed late (14.0%), and 4 never resumed (21.1%). There was no increased hazard of the composite outcome (hazard ratio [HR], 1.1 [95% CI, 0.2-6.0]), AIS, or worsening or new ICH among patients resumed early versus late. There was no difference in the composite among patients never resumed versus resumed. Patients who never resumed anticoagulation had significantly more severe ICH (median Glasgow Coma Scale: 10.6, 13.9, and 13.9 among those who resumed never, early, and late, respectively; P=0.0001), higher in-hospital mortality (56.5%, 0%, and 0%, respectively; P<0.0001), and an elevated 30-day AIS risk (HR, 15.9 [95% CI, 1.9-129.7], P=0.0098). CONCLUSIONS In this study of patients with ICH and mechanical heart valves, there was no difference in 30-day thrombotic and hemorrhagic brain-related outcomes when anticoagulation was resumed within 7 versus 7 to 30 days after ICH. Withholding anticoagulation >30 days was associated with severe baseline ICH, higher in-hospital case fatality, and elevated AIS risk.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy Massachusetts General Hospital Boston MA
| | | | | | | | - M E Gurol
- Department of Neurology Massachusetts General Hospital Boston MA
| | - Saef Izzy
- Department of Neurology Brigham Women Hospital Boston MA
| | - Richa Sharma
- Department of Neurology Yale Medicine New Haven CT
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Radmanesh F, Izzy S, Rotem RS, Tahir Z, Rademaker QJ, Yahya T, Mashlah A, Taylor HA, Weisskopf MG, Zafonte RD, Baggish AL, Grashow R. Risk of Long-Term Ischemic Stroke in Patients With Traumatic Brain Injury and Incident Hypertension. Neurotrauma Rep 2024; 5:462-466. [PMID: 38666008 PMCID: PMC11044850 DOI: 10.1089/neur.2024.0015] [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] [Subscribe] [Scholar Register] [Indexed: 04/28/2024] Open
Abstract
Traumatic brain injury (TBI) is independently associated with hypertension and ischemic stroke. The goal of this study was to determine the interplay between TBI and incident hypertension in the occurrence of post-TBI stroke. This prospective study used a hospital-based registry to identify patients without pre-existing comorbidities. TBI patients (n = 3664) were frequency matched on age, sex, and race to non-TBI patients (n = 1848). Follow-up started 6 months post-TBI or study entry and extended up to 10 years. To examine hypertension's role in post-TBI stroke, we used logistic regression models to calculate the effect estimates for stroke in four exposure categories that included TBI or hypertension in isolation and in combination. Second, we calculated the conditional direct effect (CDE) of TBI in models that considered hypertension as intermediary. Third, we examined whether TBI effect was modified by antihypertensive medication use. The 10-year cumulative incidence of stroke was higher in the TBI group (4.7%) than the non-TBI group (1.3%; p < 0.001). TBI patients who developed hypertension had the highest risk of stroke (odds ratio [OR] = 4.83, 95% confidence interval [CI] = 2.53-9.23, p < 0.001). The combined effect estimates were less than additive, suggesting an overlapping biological pathway. The total effect of TBI (OR = 3.16, 95% CI = 1.94-5.16, p < 0.001) was higher than the CDE that accounted for hypertension (OR = 2.45, 95% CI = 0.93-6.47, p = 0.06). Antihypertensives attenuated the TBI effect, suggesting that the TBI effect on stroke is partially mediated through hypertension. TBI is an independent risk factor for long-term stroke, and the underlying biological pathway may partly operate through TBI-precipitated hypertension. These findings suggest that screening for hypertension may mitigate stroke risk in TBI.
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Affiliation(s)
- Farid Radmanesh
- Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Division of Neurocritical Care, Department of Neurology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Saef Izzy
- Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Football Players Health Study at Harvard University, Boston, Massachusetts, USA
| | - Ran S. Rotem
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Zabreen Tahir
- Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Department of Neurology, Houston Methodist Hospital, Houston, Texas, USA
| | - Quinn J. Rademaker
- Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Taha Yahya
- Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ahmad Mashlah
- Divisions of Stroke, Cerebrovascular and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Herman A. Taylor
- Football Players Health Study at Harvard University, Boston, Massachusetts, USA
- Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Marc G. Weisskopf
- Football Players Health Study at Harvard University, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ross D. Zafonte
- Football Players Health Study at Harvard University, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Aaron L. Baggish
- Football Players Health Study at Harvard University, Boston, Massachusetts, USA
- Institute for Sport Science and Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Rachel Grashow
- Football Players Health Study at Harvard University, Boston, Massachusetts, USA
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
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Izzy S. Traumatic Spinal Cord Injury. Continuum (Minneap Minn) 2024; 30:53-72. [PMID: 38330472 PMCID: PMC10869103 DOI: 10.1212/con.0000000000001392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE This article provides a review of the initial clinical and radiologic evaluation and treatment of patients with traumatic spinal cord injuries. It specifically highlights essential knowledge for neurologists who encounter patients with these complex injuries. LATEST DEVELOPMENTS There has been improvement in the care of patients with traumatic spinal cord injuries, particularly in the prehospital evaluation, approach for immediate immobilization, standardized spinal clearance, efficient triage, and transportation of appropriate patients to traumatic spinal cord injury specialized centers. Advancements in spinal instrumentation have improved the surgical management of spinal fractures and the ability to manage patients with spinal mechanical instability. The clinical evidence favors performing early surgical decompression and spine stabilization within 24 hours of traumatic spinal cord injuries, regardless of the severity or location of the injury. There is no evidence that supports the use of neuroprotective treatments to improve outcomes in patients with traumatic spinal cord injuries. The administration of high-dose methylprednisolone, which is associated with significant systemic adverse effects, is strongly discouraged. Early and delayed mortality rates continue to be high in patients with traumatic spinal cord injuries, and survivors often confront substantial long-term physical and functional impairments. Whereas the exploration of neuroregenerative approaches, such as stem cell transplantation, is underway, these methods remain largely investigational. Further research is still necessary to advance the functional recovery of patients with traumatic spinal cord injuries. ESSENTIAL POINTS Traumatic spinal cord injury is a complex and devastating condition that leads to long-term neurologic deficits with profound physical, social, and vocational implications, resulting in a diminished quality of life, particularly for severely affected patients. The initial management of traumatic spinal cord injuries demands comprehensive interdisciplinary care to address the potentially catastrophic multisystem effects. Ongoing endeavors are focused on optimizing and customizing initial management approaches and developing effective therapies for neuroprotection and neuroregeneration to enhance long-term functional recovery.
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Abou-El-Hassan H, Bernstock JD, Chalif JI, Yahya T, Rezende RM, Weiner HL, Izzy S. Elucidating the neuroimmunology of traumatic brain injury: methodological approaches to unravel intercellular communication and function. Front Cell Neurosci 2023; 17:1322325. [PMID: 38162004 PMCID: PMC10756680 DOI: 10.3389/fncel.2023.1322325] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 11/15/2023] [Indexed: 01/03/2024] Open
Abstract
The neuroimmunology of traumatic brain injury (TBI) has recently gained recognition as a crucial element in the secondary pathophysiological consequences that occur following neurotrauma. Both immune cells residing within the central nervous system (CNS) and those migrating from the periphery play significant roles in the development of secondary brain injury. However, the precise mechanisms governing communication between innate and adaptive immune cells remain incompletely understood, partly due to a limited utilization of relevant experimental models and techniques. Therefore, in this discussion, we outline current methodologies that can aid in the exploration of TBI neuroimmunology, with a particular emphasis on the interactions between resident neuroglial cells and recruited lymphocytes. These techniques encompass adoptive cell transfer, intra-CNS injection(s), selective cellular depletion, genetic manipulation, molecular neuroimaging, as well as in vitro co-culture systems and the utilization of organoid models. By incorporating key elements of both innate and adaptive immunity, these methods facilitate the examination of clinically relevant interactions. In addition to these preclinical approaches, we also detail an emerging avenue of research that seeks to leverage human biofluids. This approach enables the investigation of how resident and infiltrating immune cells modulate neuroglial responses after TBI. Considering the growing significance of neuroinflammation in TBI, the introduction and application of advanced methodologies will be pivotal in advancing translational research in this field.
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Affiliation(s)
- Hadi Abou-El-Hassan
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Joshua D. Bernstock
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- David H. Koch Institute for Integrative Cancer Research, Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Joshua I. Chalif
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Taha Yahya
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Rafael M. Rezende
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Howard L. Weiner
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Saef Izzy
- Ann Romney Center for Neurologic Diseases, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
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Snider SB, Temkin NR, Barber J, Edlow BL, Giacino JT, Hammond FM, Izzy S, Kowalski RG, Markowitz AJ, Rovito CA, Shih SL, Zafonte RD, Manley GT, Bodien YG. Predicting Functional Dependency in Patients with Disorders of Consciousness: A TBI-Model Systems and TRACK-TBI Study. Ann Neurol 2023; 94:1008-1023. [PMID: 37470289 PMCID: PMC10799195 DOI: 10.1002/ana.26741] [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: 03/28/2023] [Revised: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE It is not currently possible to predict long-term functional dependency in patients with disorders of consciousness (DoC) after traumatic brain injury (TBI). Our objective was to fit and externally validate a prediction model for 1-year dependency in patients with DoC ≥ 2 weeks after TBI. METHODS We included adults with TBI enrolled in TBI Model Systems (TBI-MS) or Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) studies who were not following commands at rehabilitation admission or 2 weeks post-injury, respectively. We fit a logistic regression model in TBI-MS and validated it in TRACK-TBI. The primary outcome was death or dependency at 1 year post-injury, defined using the Disability Rating Scale. RESULTS In the TBI-MS Discovery Sample, 1,960 participants (mean age 40 [18] years, 76% male, 68% white) met inclusion criteria, and 406 (27%) were dependent 1 year post-injury. In a TBI-MS held out cohort, the dependency prediction model's area under the receiver operating characteristic curve was 0.79 (95% CI 0.74-0.85), positive predictive value was 53% and negative predictive value was 86%. In the TRACK-TBI external validation (n = 124, age 40 [16] years, 77% male, 81% white), the area under the receiver operating characteristic curve was 0.66 (0.53, 0.79), equivalent to the standard IMPACTcore + CT score (p = 0.8). INTERPRETATION We developed a 1-year dependency prediction model using the largest existing cohort of patients with DoC after TBI. The sensitivity and negative predictive values were greater than specificity and positive predictive values. Accuracy was diminished in an external sample, but equivalent to the IMPACT model. Further research is needed to improve dependency prediction in patients with DoC after TBI. ANN NEUROL 2023;94:1008-1023.
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Affiliation(s)
- Samuel B. Snider
- Division of Neurocritical Care, Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nancy R. Temkin
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Biostatistics, University of Washington, Seattle, Washington, USA
| | - Jason Barber
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Brian L. Edlow
- Harvard Medical School, Boston, MA, USA
- Center for Neurotechnology and Neurorecovery and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - Joseph T. Giacino
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Saef Izzy
- Division of Neurocritical Care, Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Robert G. Kowalski
- Departments of Neurosurgery and Neurology, University of Colorado School of Medicine, Aurora CO, USA
| | | | - Craig A. Rovito
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Shirley L. Shih
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Ross D. Zafonte
- Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, UCSF, San Francisco, CA USA
- Brain and Spinal Cord Injury Center, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, CA USA
| | - Yelena G. Bodien
- Harvard Medical School, Boston, MA, USA
- Center for Neurotechnology and Neurorecovery and Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Boston, MA USA
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Izzy S, Grashow R, Radmanesh F, Chen P, Taylor H, Formisano R, Wilson F, Wasfy M, Baggish A, Zafonte R. Long-term risk of cardiovascular disease after traumatic brain injury: screening and prevention. Lancet Neurol 2023; 22:959-970. [PMID: 37739576 PMCID: PMC10863697 DOI: 10.1016/s1474-4422(23)00241-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [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: 02/22/2023] [Revised: 06/20/2023] [Accepted: 06/23/2023] [Indexed: 09/24/2023]
Abstract
Traumatic brain injury (TBI) is highly prevalent among individuals participating in contact sports, military personnel, and in the general population. Although it is well known that brain injury can cause neurological and psychiatric complications, evidence from studies on individuals exposed to a single or repetitive brain injuries suggests an understudied association between TBI and the risk of developing chronic cardiovascular diseases and risk factors for cardiovascular disease. Several studies have shown that people without pre-existing comorbidities who sustain a TBI have a significantly higher risk of developing chronic cardiovascular disease, than people without TBI. Similar observations made in military and professional American-style football cohorts suggest causal pathways through which modifiable cardiovascular risk factors might mediate the relationship between brain injury and chronic neurological diseases. A better understanding of cardiovascular disease risk after TBI combined with a proactive, targeted screening programme might mitigate long-term morbidity and mortality in individuals with TBI, and improve their quality of life.
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Affiliation(s)
- Saef Izzy
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Football Players Health Study at Harvard University, Boston, MA, USA
| | - Rachel Grashow
- Department of Environmental Health, T H Chan School of Public Health, Harvard University, Boston, MA, USA; Football Players Health Study at Harvard University, Boston, MA, USA
| | - Farid Radmanesh
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA; Department of Neurology, Division of Neurocritical Care, University of New Mexico, Albuquerque, NM, USA
| | - Patrick Chen
- Department of Neurology, University of California Irvine, Orange, CA, USA
| | - Herman Taylor
- Football Players Health Study at Harvard University, Boston, MA, USA; Morehouse School of Medicine, Atlanta, GA, USA
| | | | - Fiona Wilson
- School of Medicine, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Meagan Wasfy
- Harvard Medical School, Boston, MA, USA; Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Aaron Baggish
- Football Players Health Study at Harvard University, Boston, MA, USA; Institute for Sport Science and Department of Cardiology, Lausanne University Hospital, Lausanne, Switzerland
| | - Ross Zafonte
- Harvard Medical School, Boston, MA, USA; Football Players Health Study at Harvard University, Boston, MA, USA; Spaulding Rehabilitation Hospital, Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, MA, USA.
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Dolmans RGF, Harary M, Nawabi N, Taros T, Kilgallon JL, Mekary RA, Izzy S, Dawood HY, Stopa BM, Broekman MLD, Gormley WB. External Ventricular Drains versus Intraparenchymal Pressure Monitors in the Management of Moderate to Severe Traumatic Brain Injury: Experience at Two Academic Centers over a Decade. World Neurosurg 2023; 178:e221-e229. [PMID: 37467955 DOI: 10.1016/j.wneu.2023.07.037] [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] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/10/2023] [Indexed: 07/21/2023]
Abstract
OBJECTIVE The choice between external ventricular drain (EVD) and intraparenchymal monitor (IPM) for managing intracranial pressure in moderate-to-severe traumatic brain injury (msTBI) patients remains controversial. This study aimed to investigate factors associated with receiving EVD versus IPM and to compare outcomes and clinical management between EVD and IPM patients. METHODS Adult msTBI patients at 2 similar academic institutions were identified. Logistic regression was performed to identify factors associated with receiving EVD versus IPM (model 1) and to compare EVD versus IPM in relation to patient outcomes after controlling for potential confounders (model 2), through odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Of 521 patients, 167 (32.1%) had EVD and 354 (67.9%) had IPM. Mean age, sex, and Injury Severity Score were comparable between groups. Epidural hemorrhage (EDH) (OR 0.43, 95% CI 0.21-0.85), greater midline shift (OR 0.90, 95% CI 0.82-0.98), and the hospital with higher volume (OR 0.14, 95% CI 0.09-0.22) were independently associated with lower odds of receiving an EVD whereas patients needing a craniectomy were more likely to receive an EVD (OR 2.04, 95% CI 1.12-3.73). EVD patients received more intense medical treatment requiring hyperosmolar therapy compared to IPM patients (64.1% vs. 40.1%). No statistically significant differences were found in patient outcomes. CONCLUSIONS While EDH, greater midline shift, and hospital with larger patient volume were associated with receiving an IPM, the need for a craniectomy was associated with receiving an EVD. EVD patients received different clinical management than IPM patients with no significant differences in patient outcomes.
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Affiliation(s)
- Rianne G F Dolmans
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Maya Harary
- Department of Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Noah Nawabi
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Trenton Taros
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John L Kilgallon
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rania A Mekary
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Hassan Y Dawood
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brittany M Stopa
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Marike L D Broekman
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurosurgery, Leiden University Medical Center, Leiden, The Netherlands
| | - William B Gormley
- Department of Neurosurgery, Computational Neuroscience Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Kim M, Subah G, Cooper J, Fortunato M, Nolan B, Bowers C, Prabhakaran K, Nuoman R, Amuluru K, Soldozy S, Das AS, Regenhardt RW, Izzy S, Gandhi C, Al-Mufti F. Neuroendovascular Surgery Applications in Craniocervical Trauma. Biomedicines 2023; 11:2409. [PMID: 37760850 PMCID: PMC10525707 DOI: 10.3390/biomedicines11092409] [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: 06/29/2023] [Revised: 08/12/2023] [Accepted: 08/22/2023] [Indexed: 09/29/2023] Open
Abstract
Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.
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Affiliation(s)
- Michael Kim
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Michael Fortunato
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Bridget Nolan
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87108, USA
| | - Kartik Prabhakaran
- Department of Surgery, Division of Trauma and Acute Care Surgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children’s Hospital, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Indianapolis, IN 46032, USA
| | - Sauson Soldozy
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Alvin S. Das
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA
| | - Robert W. Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02215, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY 10595, USA
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Abou-El-Hassan H, Rezende RM, Izzy S, Gabriely G, Yahya T, Tatematsu BK, Habashy KJ, Lopes JR, de Oliveira GLV, Maghzi AH, Yin Z, Cox LM, Krishnan R, Butovsky O, Weiner HL. Vγ1 and Vγ4 gamma-delta T cells play opposing roles in the immunopathology of traumatic brain injury in males. Nat Commun 2023; 14:4286. [PMID: 37463881 DOI: 10.1038/s41467-023-39857-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 06/30/2023] [Indexed: 07/20/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality. The innate and adaptive immune responses play an important role in the pathogenesis of TBI. Gamma-delta (γδ) T cells have been shown to affect brain immunopathology in multiple different conditions, however, their role in acute and chronic TBI is largely unknown. Here, we show that γδ T cells affect the pathophysiology of TBI as early as one day and up to one year following injury in a mouse model. TCRδ-/- mice are characterized by reduced inflammation in acute TBI and improved neurocognitive functions in chronic TBI. We find that the Vγ1 and Vγ4 γδ T cell subsets play opposing roles in TBI. Vγ4 γδ T cells infiltrate the brain and secrete IFN-γ and IL-17 that activate microglia and induce neuroinflammation. Vγ1 γδ T cells, however, secrete TGF-β that maintains microglial homeostasis and dampens TBI upon infiltrating the brain. These findings provide new insights on the role of different γδ T cell subsets after brain injury and lay down the principles for the development of targeted γδ T-cell-based therapy for TBI.
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Affiliation(s)
- Hadi Abou-El-Hassan
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rafael M Rezende
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Saef Izzy
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Galina Gabriely
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Taha Yahya
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bruna K Tatematsu
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karl J Habashy
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Juliana R Lopes
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Gislane L V de Oliveira
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Amir-Hadi Maghzi
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zhuoran Yin
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Laura M Cox
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rajesh Krishnan
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Oleg Butovsky
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
- Evergrande Center for Immunologic Diseases, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Howard L Weiner
- Ann Romney Center for Neurologic Diseases, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
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10
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Bilodeau PA, Aghajan Y, Izzy S. Rash, Facial Droop, and Multifocal Intracranial Stenosis Due to Varicella Zoster Virus Vasculitis. Neurohospitalist 2023; 13:178-182. [PMID: 37064929 PMCID: PMC10091438 DOI: 10.1177/19418744221150301] [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: 04/07/2023] Open
Abstract
Background: This is a case of multifocal intracranial stenosis in a 74 year old male ultimately discovered to be due to Varicella Zoster Virus infection. Purpose: We highlight the importance of a broad differential diagnosis, even when the most likely etiology of intracranial stenosis is atherosclerosis. Our paper reviews the differential diagnosis as well as "red flags" for intracranial vasculopathy. Even though intracranial atherosclerotic disease is the most common cause of vasculopathy, infectious or inflammatory vasculitis should be considered on the differential. Conclusions: Before considering bypass surgery or other invasive neurosurgical procedures, ensure reversible causes of vasculopathy have been ruled out. The presence of cranial neuropathies, rash, and/or elevated inflammatory markers should be red flags for vasculitis in patients presenting with stroke.
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Affiliation(s)
| | | | - Saef Izzy
- Brigham and Women's
Hospital, Boston, MA, USA
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11
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Bernstock JD, Willis CM, Garcia-Segura ME, Gaude E, Anni D, Lee YJ, Thomas LW, Casey A, Vicario N, Leonardi T, Nicaise AM, Gessler FA, Izzy S, Buffelli MR, Seidlitz J, Srinivasan S, Murphy MP, Ashcroft M, Cambiaghi M, Hallenbeck JM, Peruzzotti-Jametti L. Integrative transcriptomic and metabolic analyses of the mammalian hibernating brain identifies a key role for succinate dehydrogenase in ischemic tolerance. bioRxiv 2023:2023.03.29.534718. [PMID: 37205496 PMCID: PMC10187245 DOI: 10.1101/2023.03.29.534718] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Ischemic stroke results in a loss of tissue homeostasis and integrity, the underlying pathobiology of which stems primarily from the depletion of cellular energy stores and perturbation of available metabolites 1 . Hibernation in thirteen-lined ground squirrels (TLGS), Ictidomys tridecemlineatus , provides a natural model of ischemic tolerance as these mammals undergo prolonged periods of critically low cerebral blood flow without evidence of central nervous system (CNS) damage 2 . Studying the complex interplay of genes and metabolites that unfolds during hibernation may provide novel insights into key regulators of cellular homeostasis during brain ischemia. Herein, we interrogated the molecular profiles of TLGS brains at different time points within the hibernation cycle via RNA sequencing coupled with untargeted metabolomics. We demonstrate that hibernation in TLGS leads to major changes in the expression of genes involved in oxidative phosphorylation and this is correlated with an accumulation of the tricarboxylic acid (TCA) cycle intermediates citrate, cis-aconitate, and α-ketoglutarate-αKG. Integration of the gene expression and metabolomics datasets led to the identification of succinate dehydrogenase (SDH) as the critical enzyme during hibernation, uncovering a break in the TCA cycle at that level. Accordingly, the SDH inhibitor dimethyl malonate (DMM) was able to rescue the effects of hypoxia on human neuronal cells in vitro and in mice subjected to permanent ischemic stroke in vivo . Our findings indicate that studying the regulation of the controlled metabolic depression that occurs in hibernating mammals may lead to novel therapeutic approaches capable of increasing ischemic tolerance in the CNS.
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12
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Snider SB, Temkin NR, Barber J, Edlow BL, Giacino JT, Hammond FM, Izzy S, Kowalski RG, Markowitz AJ, Rovito CA, Shih SL, Zafonte RD, Manley GT, Bodien YG. Predicting Functional Dependency in Patients with Disorders of Consciousness: A TBI-Model Systems and TRACK-TBI Study. medRxiv 2023:2023.03.14.23287249. [PMID: 36993195 PMCID: PMC10055467 DOI: 10.1101/2023.03.14.23287249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/19/2023]
Abstract
Importance There are currently no models that predict long-term functional dependency in patients with disorders of consciousness (DoC) after traumatic brain injury (TBI). Objective Fit, test, and externally validate a prediction model for 1-year dependency in patients with DoC 2 or more weeks after TBI. Design Secondary analysis of patients enrolled in TBI Model Systems (TBI-MS, 1988-2020, Discovery Sample) or Transforming Research and Clinical Knowledge in TBI (TRACK-TBI, 2013-2018, Validation Sample) and followed 1-year post-injury. Setting Multi-center study at USA rehabilitation hospitals (TBI-MS) and acute care hospitals (TRACK-TBI). Participants Adults with TBI who were not following commands at rehabilitation admission (TBI-MS; days post-injury vary) or 2-weeks post-injury (TRACK-TBI). Exposures In the TBI-MS database (model fitting and testing), we screened demographic, radiological, clinical variables, and Disability Rating Scale (DRS) item scores for association with the primary outcome. Main Outcome The primary outcome was death or complete functional dependency at 1-year post-injury, defined using a DRS-based binary measure (DRS Depend ), indicating need for assistance with all activities and concomitant cognitive impairment. Results In the TBI-MS Discovery Sample, 1,960 subjects (mean age 40 [18] years, 76% male, 68% white) met inclusion criteria and 406 (27%) were dependent at 1-year post-injury. A dependency prediction model had an area under the receiver operating characteristic curve (AUROC) of 0.79 [0.74, 0.85], positive predictive value of 53%, and negative predictive value of 86% for dependency in a held-out TBI-MS Testing cohort. Within the TRACK-TBI external validation sample (N=124, age 40 [16], 77% male, 81% white), a model modified to remove variables not collected in TRACK-TBI, had an AUROC of 0.66 [0.53, 0.79], equivalent to the gold-standard IMPACT core+CT score (0.68; 95% AUROC difference CI: -0.2 to 0.2, p=0.8). Conclusions and Relevance We used the largest existing cohort of patients with DoC after TBI to develop, test and externally validate a prediction model of 1-year dependency. The model’s sensitivity and negative predictive value were greater than specificity and positive predictive value. Accuracy was diminished in an external sample, but equivalent to the best-available models. Further research is needed to improve dependency prediction in patients with DoC after TBI.
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13
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Grashow R, Tan CO, Izzy S, Taylor HA, Weisskopf MG, Wasfy MM, Whittington AJ, Speizer F, Zafonte R, Baggish AL. Association Between Concussion Burden During Professional American-style Football and Post-career Hypertension. Circulation 2023; 147:1112-1114. [PMID: 36748510 DOI: 10.1161/circulationaha.122.063767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Rachel Grashow
- Football Players Health Study at Harvard University, Harvard Medical School, Boston, MA; Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Can Ozan Tan
- RAM Group, Department of Electrical Engineering, Mathematics, and Computer Science, University of Twente, the Netherlands
| | - Saef Izzy
- Department of Neurology, Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Herman A Taylor
- Football Players Health Study at Harvard University, Harvard Medical School, Boston, MA; Cardiovascular Research Institute, Morehouse School of Medicine, Atlanta, GA
| | - Marc G Weisskopf
- Football Players Health Study at Harvard University, Harvard Medical School, Boston, MA; Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA
| | - Meagan M Wasfy
- Football Players Health Study at Harvard University, Harvard Medical School, Boston, MA; Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Alicia J Whittington
- Football Players Health Study at Harvard University, Harvard Medical School, Boston, MA
| | - Frank Speizer
- Football Players Health Study at Harvard University, Harvard Medical School, Boston, MA; Department of Environmental Health, Harvard T. H. Chan School of Public Health, Boston, MA; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ross Zafonte
- Football Players Health Study at Harvard University, Harvard Medical School, Boston, MA; Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Charlestown, MA
| | - Aaron L Baggish
- Football Players Health Study at Harvard University, Harvard Medical School, Boston, MA; Cardiovascular Performance Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Department of Cardiology, Lausanne University Hospital (CHUV) and Institute for Sport Science, University of Lausanne (ISSUL), Lausanne, Switzerland
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14
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Forman R, Barra M, Bianca Long-Fazio B, Merkler AE, Izzy S, Sharma R. Abstract TMP83: Optimal Timing For Resumption Of Anticoagulation After Intracranial Hemorrhage In Patients With Mechanical Heartvalves. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tmp83] [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] [Indexed: 02/05/2023]
Abstract
Introduction:
Anticoagulation in patients with acute intracranial hemorrhage (ICH) and mechanical heart valves (MHV) is often held to mitigate the risk of ICH expansion or recurrence; however there exists a competing risk of acute ischemic stroke (AIS). Optimal timing to resume anticoagulation after ICH remains uncertain.
Methods:
We retrospectively studied ICH patients with MHV at two academic hospitals from April, 2000-August, 2018. The primary outcome was a composite endpoint of symptomatic hematoma expansion or new ICH, AIS, and intracardiac thrombus up to 30 days post-ICH. The exposure was timing of re-initiation of anticoagulation classified as early if therapeutic anticoagulation was resumed up to 7 days after ICH; late if ≥7 and up to 30 days after ICH; and never if not resumed or resumed after 30-days post-ICH. Cox proportional hazard models were built adjusted for age, sex, and covariates significantly different in univariate analysis at a pre-specified p-value threshold of 0.05.
Results:
We identified 184 patients with ICH and MHV (65 anticoagulated early, 100 resumed late, 19 not resumed by day 30 post-ICH). We observed 12 AIS, 16 new ICH, and 6 intracardiac thromboses. The mean time from ICH to anticoagulation in the cohort was 12.7 days. Patients resumed early versus late were more likely to have atrial fibrillation (62% versus 42%), and less likely to be reversed (75% versus 94%), to undergo hematoma evacuation (23% versus 43%), have midline shift (27% versus 52.9%), and to have intracerebral involvement (26% versus 49%). There was no significant difference in the hazard of AIS, new or symptomatic ICH expansion, or the composite outcome among those resumed early versus late. Patients not resumed within 30 days post-ICH had a significantly higher risk of AIS compared to those resumed within 30 days (HR 15.9; 95% C.I.1.9-129.7, p=0.0098).
Discussion:
In this study of ICH patients with MHV, there was no difference in the 30-day thrombotic and hemorrhagic brain-related outcomes in patients anticoagulated within 7 days versus 7-30 days. Withholding anticoagulation within the first 30 days was associated with a significantly higher risk of AIS. Our findings provide a discrete time window to guide resumption of anticoagulation in MHV patients with ICH.
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Affiliation(s)
| | | | | | | | - Saef Izzy
- Brigham and Women's Hosp, Boston, MA
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15
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Bhave VM, Bernstock JD, Carlson JM, Kappel AD, Torio EF, Chen JA, Essayed WI, Gawelek KL, DiToro DF, Izzy S, Cosgrove GR. Surgical Management in Herpes Simplex Encephalitis: Illustrative Case Report and Systematic Review of the Literature. Neurosurgery 2023; 92:915-933. [PMID: 36700784 DOI: 10.1227/neu.0000000000002334] [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: 09/13/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Herpes simplex virus (HSV) is a common cause of viral encephalitis and can result in refractory seizures. Although HSV encephalitis (HSVE) is treated primarily with acyclovir, surgery can play a role in medically intractable cases. OBJECTIVE To systematically review cases describing surgery for the treatment of severe HSVE. We also present an illustrative case of anterior temporal lobectomy (ATL) for refractory status epilepticus in a patient with unilateral HSVE. This case demonstrates one clinical context in which surgery can be a useful adjunct. METHODS We performed a systematic review using PubMed and Google Scholar, including case reports and series describing surgical interventions for HSVE. Clinical data were extracted from 54 publications that incorporated 67 patient cases. RESULTS Surgical decompression occurred at a wide range of times after the onset of illness, although most patients were operated on 4 or more days after HSVE symptoms began. Numerous reports indicated that decompressive craniectomy, temporal lobectomy, and hematoma removal could treat intractably elevated intracranial pressure because of HSVE with favorable long-term outcomes. We describe an additional case in which a 52-year-old woman with HSVE developed refractory right temporal lobe seizures. After ATL, the seizures resolved with significant clinical improvement. CONCLUSION Surgical treatment can be a useful adjunct for treatment of HSVE. There is substantial variability in the timing of surgical decompression in patients with HSVE, which can be necessary up to approximately 3 weeks after illness onset. ATL should be considered for refractory status epilepticus in HSVE with a unilateral seizure focus.
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Affiliation(s)
| | - Joshua D Bernstock
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julia M Carlson
- Division of Neurocritical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ari D Kappel
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Erickson F Torio
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jason A Chen
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walid Ibn Essayed
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kara L Gawelek
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel F DiToro
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - G Rees Cosgrove
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
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16
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Reilly AS, Khawaja AM, Ali AB, Madsen T, Molino-Bacic J, Heffernan DS, Zonfrillo MR, Vaitkevicius H, Gormley WB, Izzy S, Rao SS. Disparities in Decompressive Cranial Surgery Utilization in Severe Traumatic Brain Injury Patients without a Primary Extra-Axial Hematoma: A U.S. Nationwide Study. World Neurosurg 2023; 169:e16-e28. [PMID: 36202343 DOI: 10.1016/j.wneu.2022.09.113] [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: 06/17/2022] [Revised: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Decompressive craniectomy is recommended to reduce mortality in severe traumatic brain injury (TBI). Disparities exist in TBI treatment outcomes; however, data on disparities pertaining to decompressive craniectomy utilization is lacking. We investigated these disparities, focusing on race, insurance, sex, and age. METHODS Hospitalizations (2004-2014) were retrospectively extracted from the Nationwide Inpatient Sample. The criteria included are as follows: age ≥18 years and indicators of severe TBI diagnosis. Poor outcomes were defined as discharge to institutional care and death. Multivariable logistic regression models were used to assess the effects of race, insurance, age, and sex, on craniectomy utilization and outcomes. RESULTS Of 349,164 hospitalized patients, 6.8% (n = 23,743) underwent craniectomy. White (odds ratio [OR] = 0.50, 95% confidence interval [CI] = 0.44-0.57; P < 0.001) and Black (OR = 0.45, 95% CI = 0.32-0.64; P = 0.003) Medicare beneficiaries were less likely to undergo craniectomy. Medicare (P < 0.0001) and Medicaid beneficiaries (P < 0.0001) of all race categories had poorer outcomes than privately insured White patients. Black (OR = 1.2, 95% CI = 1.08-2.34; P = 0.001) patients with private insurance and Black (OR = 1.39, 95% CI = 1.22-1.58; P < 0.0001) Medicaid beneficiaries had poorer outcomes than privately insured White patients (P < 0.0001). Older patients (OR = 0.74, 95%, CI = 0.71-0.76; P < 0.001) were less likely to undergo craniectomy and were more likely to have poorer outcomes. Females (OR = 0.82, 95% CI = 0.76-0.88; P < 0.001) were less likely to undergo craniectomy. CONCLUSIONS There are disparities in race, insurance status, sex, and age in craniectomy utilization and outcome. This data highlights the necessity to appropriately address these disparities, especially race and sex, and actively incorporate these factors in clinical trial design and enrollment.
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Affiliation(s)
- Aoife S Reilly
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; RCSI, University of Medicine and Health Sciences, Dublin, Ireland.
| | - Ayaz M Khawaja
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Neurology, Wayne State University, Detroit, Michigan, USA
| | - Ali Basil Ali
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; RCSI, University of Medicine and Health Sciences, Dublin, Ireland
| | - Tracy Madsen
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Janine Molino-Bacic
- Department of Orthopedics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Daithi S Heffernan
- Department of Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Mark R Zonfrillo
- Department of Emergency Medicine and Pediatrics, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - William B Gormley
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Shyam S Rao
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Neurology, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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17
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Snider SB, Kowalski RG, Hammond FM, Izzy S, Shih SL, Rovito C, Edlow BL, Zafonte RD, Giacino JT, Bodien YG. Comparison of Common Outcome Measures for Assessing Independence in Patients Diagnosed with Disorders of Consciousness: A Traumatic Brain Injury Model Systems Study. J Neurotrauma 2022; 39:1222-1230. [PMID: 35531895 PMCID: PMC9422782 DOI: 10.1089/neu.2022.0076] [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: 11/12/2022] Open
Abstract
Patients with disorders of consciousness (DoC) after traumatic brain injury (TBI) recover to varying degrees of functional dependency. Dependency is difficult to measure but critical for interpreting clinical trial outcomes and prognostic counseling. In participants with DoC (i.e., not following commands) enrolled in the TBI Model Systems National Database (TBIMS NDB), we used the Functional Independence Measure (FIM®) as the reference to evaluate how accurately the Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale (DRS) assess dependency. Using the established FIM-dependency cut-point of <80, we measured the classification performance of literature-derived GOSE and DRS cut-points at 1-year post-injury. We compared the area under the receiver operating characteristic curve (AUROC) between the DRSDepend, a DRS-derived marker of dependency, and the data-derived optimal GOSE and DRS cut-points. Of 18,486 TBIMS participants, 1483 met inclusion criteria (mean [standard deviation (SD)] age = 38 [18] years; 76% male). The sensitivity of GOSE cut-points of ≤3 and ≤4 (Lower Severe and Upper Severe Disability, respectively) for identifying FIM-dependency were 97% and 98%, but specificities were 73% and 51%, respectively. The sensitivity of the DRS cut-point of ≥12 (Severe Disability) for identifying FIM-dependency was 60%, but specificity was 100%. The DRSDepend had a sensitivity of 83% and a specificity of 94% for classifying FIM-dependency, with a greater AUROC than the data-derived optimal GOSE (≤3, p = 0.01) and DRS (≥10, p = 0.008) cut-points. Commonly used GOSE and DRS cut-points have limited specificity or sensitivity for identifying functional dependency. The DRSDepend identifies FIM-dependency more accurately than the GOSE and DRS cut-points, but requires further validation.
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Affiliation(s)
- Samuel B. Snider
- Department of Neurology, Division of Neurocritical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Address correspondence to: Samuel B. Snider, MD, Department of Neurology, Division of Neurocritical Care, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02115
| | - Robert G. Kowalski
- Departments of Neurosurgery and Neurology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Flora M. Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Saef Izzy
- Department of Neurology, Division of Neurocritical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Shirley L. Shih
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
| | - Craig Rovito
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
| | - Brian L. Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA.,Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, Massachusetts, USA
| | - Ross D. Zafonte
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
| | - Joseph T. Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, Massachusetts, USA
| | - Yelena G. Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, Massachusetts, USA.,Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts, USA
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18
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Izzy S, Chen PM, Tahir Z, Grashow R, Radmanesh F, Cote DJ, Yahya T, Dhand A, Taylor H, Shih SL, Albastaki O, Rovito C, Snider SB, Whalen M, Nathan DM, Miller KK, Speizer FE, Baggish A, Weisskopf MG, Zafonte R. Association of Traumatic Brain Injury With the Risk of Developing Chronic Cardiovascular, Endocrine, Neurological, and Psychiatric Disorders. JAMA Netw Open 2022; 5:e229478. [PMID: 35482306 PMCID: PMC9051987 DOI: 10.1001/jamanetworkopen.2022.9478] [Citation(s) in RCA: 42] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Increased risk of neurological and psychiatric conditions after traumatic brain injury (TBI) is well-defined. However, cardiovascular and endocrine comorbidity risk after TBI in individuals without these comorbidities and associations with post-TBI mortality have received little attention. OBJECTIVE To assess the incidence of cardiovascular, endocrine, neurological, and psychiatric comorbidities in patients with mild TBI (mTBI) or moderate to severe TBI (msTBI) and analyze associations between post-TBI comorbidities and mortality. DESIGN, SETTING, AND PARTICIPANTS This prospective longitudinal cohort study used hospital-based patient registry data from a tertiary academic medical center to select patients without any prior clinical comorbidities who experienced TBI from 2000 to 2015. Using the same data registry, individuals without head injuries, the unexposed group, and without target comorbidities were selected and age-, sex-, and race-frequency-matched to TBI subgroups. Patients were followed-up for up to 10 years. Data were analyzed in 2021. EXPOSURES Mild or moderate to severe head trauma. MAIN OUTCOMES AND MEASURES Cardiovascular, endocrine, neurologic, and psychiatric conditions were defined based on International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Associations between TBI and comorbidities, as well as associations between the comorbidities and mortality, were analyzed. RESULTS A total of 4351 patients with mTBI (median [IQR] age, 45 [29-57] years), 4351 patients with msTBI (median [IQR] age, 47 [30-58] years), and 4351 unexposed individuals (median [IQR] age, 46 [30-58] years) were included in analyses. In each group, 45% of participants were women. mTBI and msTBI were significantly associated with higher risks of cardiovascular, endocrine, neurologic, and psychiatric disorders compared with unexposed individuals. In particular, hypertension risk was increased in both mTBI (HR, 2.5; 95% CI, 2.1-2.9) and msTBI (HR, 2.4; 95% CI, 2.0-2.9) groups. Diabetes risk was increased in both mTBI (HR, 1.9; 95% CI, 1.4-2.7) and msTBI (HR, 1.9; 95% CI, 1.4-2.6) groups, and risk of ischemic stroke or transient ischemic attack was also increased in mTBI (HR, 2.2; 95% CI, 1.4-3.3) and msTBI (HR, 3.6; 95% CI, 2.4-5.3) groups. All comorbidities in the TBI subgroups emerged within a median (IQR) of 3.49 (1.76-5.96) years after injury. Risks for post-TBI comorbidities were also higher in patients aged 18 to 40 years compared with age-matched unexposed individuals: hypertension risk was increased in the mTBI (HR, 5.9; 95% CI, 3.9-9.1) and msTBI (HR, 3.9; 95% CI, 2.5-6.1) groups, while hyperlipidemia (HR, 2.3; 95% CI, 1.5-3.4) and diabetes (HR, 4.6; 95% CI, 2.1-9.9) were increased in the mTBI group. Individuals with msTBI, compared with unexposed patients, had higher risk of mortality (432 deaths [9.9%] vs 250 deaths [5.7%]; P < .001); postinjury hypertension (HR, 1.3; 95% CI, 1.1-1.7), coronary artery disease (HR, 2.2; 95% CI, 1.6-3.0), and adrenal insufficiency (HR, 6.2; 95% CI, 2.8-13.0) were also associated with higher mortality. CONCLUSIONS AND RELEVANCE These findings suggest that TBI of any severity was associated with a higher risk of chronic cardiovascular, endocrine, and neurological comorbidities in patients without baseline diagnoses. Medical comorbidities were observed in relatively young patients with TBI. Comorbidities occurring after TBI were associated with higher mortality. These findings suggest the need for a targeted screening program for multisystem diseases after TBI, particularly chronic cardiometabolic diseases.
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Affiliation(s)
- Saef Izzy
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Patrick M Chen
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Zabreen Tahir
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rachel Grashow
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- The Football Players Health Study at Harvard University, Boston, Massachusetts
| | - Farid Radmanesh
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - David J Cote
- Harvard Medical School, Boston, Massachusetts
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
- Department of Neurosurgery, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Taha Yahya
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amar Dhand
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
- Network Science Institute, Northeastern University, Boston, Massachusetts
| | - Herman Taylor
- The Football Players Health Study at Harvard University, Boston, Massachusetts
- Morehouse School of Medicine, Atlanta, Georgia
| | - Shirley L Shih
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Brigham and Women's Hospital, Boston
| | - Omar Albastaki
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Craig Rovito
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
| | - Samuel B Snider
- Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Michael Whalen
- Department of Pediatrics, Massachusetts General Hospital, Boston
| | - David M Nathan
- Harvard Medical School, Boston, Massachusetts
- The Football Players Health Study at Harvard University, Boston, Massachusetts
- Diabetes Center, Massachusetts General Hospital, Boston
| | - Karen K Miller
- Harvard Medical School, Boston, Massachusetts
- The Football Players Health Study at Harvard University, Boston, Massachusetts
- Neuroendocrine Unit, Massachusetts General Hospital, Boston
| | - Frank E Speizer
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- The Football Players Health Study at Harvard University, Boston, Massachusetts
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Aaron Baggish
- Harvard Medical School, Boston, Massachusetts
- The Football Players Health Study at Harvard University, Boston, Massachusetts
- Department of Internal Medicine, Cardiovascular Performance Center, Massachusetts General Hospital, Boston
| | - Marc G Weisskopf
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- The Football Players Health Study at Harvard University, Boston, Massachusetts
| | - Ross Zafonte
- Harvard Medical School, Boston, Massachusetts
- The Football Players Health Study at Harvard University, Boston, Massachusetts
- Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Brigham and Women's Hospital, Boston
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts
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19
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Kals M, Kunzmann K, Parodi L, Radmanesh F, Wilson L, Izzy S, Anderson CD, Puccio AM, Okonkwo DO, Temkin N, Steyerberg EW, Stein MB, Manley GT, Maas AI, Richardson S, Diaz-Arrastia R, Palotie A, Ripatti S, Rosand J, Menon DK. A genome-wide association study of outcome from traumatic brain injury. EBioMedicine 2022; 77:103933. [PMID: 35301180 PMCID: PMC8927841 DOI: 10.1016/j.ebiom.2022.103933] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Factors such as age, pre-injury health, and injury severity, account for less than 35% of outcome variability in traumatic brain injury (TBI). While some residual outcome variability may be attributable to genetic factors, published candidate gene association studies have often been underpowered and subject to publication bias. METHODS We performed the first genome- and transcriptome-wide association studies (GWAS, TWAS) of genetic effects on outcome in TBI. The study population consisted of 5268 patients from prospective European and US studies, who attended hospital within 24 h of TBI, and satisfied local protocols for computed tomography. FINDINGS The estimated heritability of TBI outcome was 0·26. GWAS revealed no genetic variants with genome-wide significance (p < 5 × 10-8), but identified 83 variants in 13 independent loci which met a lower pre-specified sub-genomic statistical threshold (p < 10-5). Similarly, none of the genes tested in TWAS met tissue-wide significance. An exploratory analysis of 75 published candidate variants associated with 28 genes revealed one replicable variant (rs1800450 in the MBL2 gene) which retained significance after correction for multiple comparison (p = 5·24 × 10-4). INTERPRETATION While multiple novel loci reached less stringent thresholds, none achieved genome-wide significance. The overall heritability estimate, however, is consistent with the hypothesis that common genetic variation substantially contributes to inter-individual variability in TBI outcome. The meta-analytic approach to the GWAS and the availability of summary data allows for a continuous extension with additional cohorts as data becomes available. FUNDING A full list of funding bodies that contributed to this study can be found in the Acknowledgements section.
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Affiliation(s)
- Mart Kals
- Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, Finland
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
| | - Kevin Kunzmann
- MRC Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
| | - Livia Parodi
- Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA CPZN-6810, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Farid Radmanesh
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, United Kingdom
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Christopher D. Anderson
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Nancy Temkin
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA, USA
| | - Ewout W. Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
| | - Murray B. Stein
- Department of Psychiatry, School of Medicine, and School of Public Health, University of California, San Diego, La Jolla, CA, USA
| | - Geoff T. Manley
- Department of Neurosurgery, University of California, San Francisco, CA, USA
| | - Andrew I.R. Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Sylvia Richardson
- MRC Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Aarno Palotie
- Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, Finland
- Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA CPZN-6810, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Samuli Ripatti
- Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, Finland
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA CPZN-6810, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Box 93, Addenbrooke's Hospital, Cambridge CB2 2QQ, United Kingdom
| | - The Genetic Associations In Neurotrauma (GAIN) Consortium (with contribution from the CENTER-TBI, TRACK-TBI, CABI, MGB, and TBIcare studies)
- Institute for Molecular Medicine Finland (FIMM), HiLIFE, University of Helsinki, Helsinki, Finland
- Estonian Genome Center, Institute of Genomics, University of Tartu, Tartu, Estonia
- MRC Biostatistics Unit, Cambridge Institute of Public Health, University of Cambridge, Cambridge, United Kingdom
- Center for Genomic Medicine, Massachusetts General Hospital, 185 Cambridge Street, Boston, MA CPZN-6810, USA
- McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Psychology, University of Stirling, Stirling, United Kingdom
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
- Departments of Neurological Surgery and Biostatistics, University of Washington, Seattle, WA, USA
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
- Department of Public Health, Erasmus MC, Rotterdam, the Netherlands
- Department of Psychiatry, School of Medicine, and School of Public Health, University of California, San Diego, La Jolla, CA, USA
- Department of Neurosurgery, University of California, San Francisco, CA, USA
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
- Department of Public Health, University of Helsinki, Helsinki, Finland
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Box 93, Addenbrooke's Hospital, Cambridge CB2 2QQ, United Kingdom
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20
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Ali AB, Khawaja AM, Reilly A, Tahir Z, Rao SS, Bernstock JD, Chen P, Molino J, Gormley W, Izzy S. Venous Thromboembolism Risk and Outcomes Following Decompressive Craniectomy in Severe Traumatic Brain Injury: An Analysis of the Nationwide Inpatient Sample Database. World Neurosurg 2022; 161:e531-e545. [DOI: 10.1016/j.wneu.2022.02.069] [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] [Received: 12/01/2021] [Revised: 02/13/2022] [Accepted: 02/14/2022] [Indexed: 11/30/2022]
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21
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Moreira TG, Matos KTF, De Paula GS, Santana TMM, Da Mata RG, Pansera FC, Cortina AS, Spinola MG, Baecher-Allan CM, Keppeke GD, Jacob J, Palejwala V, Chen K, Izzy S, Healey BC, Rezende RM, Dedivitis RA, Shailubhai K, Weiner HL. Corrigendum: Nasal Administration of Anti-CD3 Monoclonal Antibody (Foralumab) Reduces Lung Inflammation and Blood Inflammatory Biomarkers in Mild to Moderate COVID-19 Patients: A Pilot Study. Front Immunol 2022; 12:815812. [PMID: 35095916 PMCID: PMC8790742 DOI: 10.3389/fimmu.2021.815812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/23/2021] [Indexed: 11/25/2022] Open
Affiliation(s)
- Thais G Moreira
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Kimble T F Matos
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | - Marcelle G Spinola
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Clare M Baecher-Allan
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Gerson D Keppeke
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jules Jacob
- Tiziana LifeScience, Doylestown, PA, United States
| | | | - Karen Chen
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Saef Izzy
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Brian C Healey
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Rafael M Rezende
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | | | | | - Howard L Weiner
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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22
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Migdady I, Chen P, Loza AM, Cashman CR, Izzy S. Cerebral Hyperperfusion and Delayed Coma Recovery after Subdural Hematoma Evacuation. J Stroke Cerebrovasc Dis 2021; 30:106165. [PMID: 34666233 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/06/2021] [Revised: 10/03/2021] [Accepted: 10/05/2021] [Indexed: 11/18/2022] Open
Abstract
Acute subdural hematoma is a devastating neurological injury with significant morbidity and mortality. In patients with large subdural hematoma resulting in compression of the underlying brain and lateral brain shift, severe neurological deficits and coma can occur. Emergent neurosurgical decompression is a life-saving intervention which improves mortality and neurological function. Persistent coma despite subdural hematoma evacuation is often the result of persistent midline shift, cerebral infarctions related to initial elevated intracranial pressure and herniation, nonconvulsive seizures, and other metabolic and infectious causes; however, a subset of patients remains comatose without a discernable etiology. In this report, we describe an elderly patient who remained comatose without a known cause for several weeks after subdural hematoma evacuation and was found to have delayed cerebral hyperperfusion on brain imaging. After several days, there was marked recovery of consciousness which occurred in a timeframe that matched improvement in brain imaging findings. Cerebral hyperperfusion following subdural hematoma evacuation requires further investigation, and should be considered as a cause of persistent but potentially recoverable coma.
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Affiliation(s)
- Ibrahim Migdady
- Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA.
| | - Patrick Chen
- Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Alejandra Márquez Loza
- Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Christopher R Cashman
- Department of Neurology, Brigham and Women's Hospital, Boston, MA; Department of Neurology, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
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23
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Gupta S, Vicenty-Padilla J, Lai PMR, Zhou X, Bernstock JD, Chua M, Izzy S, Aziz-Sultan MA, Du R, Patel NJ. Posterior Cerebral Artery Aneurysm Re-Rupture Following Revascularization for Moyamoya Disease. J Stroke Cerebrovasc Dis 2021; 30:106048. [PMID: 34534774 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106048] [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: 06/22/2021] [Revised: 07/21/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Aneurysms associated with hemorrhagic moyamoya disease (MMD) are reported to stabilize or recede following revascularization. CASE REPORT/RESULTS A 29 year-old male with no past medical history presented obtunded with diffuse intraventricular hemorrhage and vascular imaging demonstrating bilateral MMD without any associated aneurysms. He underwent a delayed right-sided STA-MCA bypass and pial synangiosis, and was subsequently discharged on hospital day 24 with a modified Rankin Scale score (mRS) of 2. He returned eleven days later from a rehabilitation facility with recurrent IVH. A saccular 5 mm right P4 segment posterior cerebral artery aneurysm was seen on a diagnostic angiogram and embolized with Onyx glue. CONCLUSIONS Distal posterior circulation artery aneurysmal rupture is a rare cause of hemorrhagic MMD. This case demonstrates the capacity of these aneurysms to re-rupture following revascularization and underscores the importance of treating the aneurysms directly.
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Affiliation(s)
- Saksham Gupta
- Department of Neurosurgery, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States.
| | - Juan Vicenty-Padilla
- Department of Neurosurgery, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
| | - Pui Man Rosalind Lai
- Department of Neurosurgery, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
| | - Xin Zhou
- Department of Neurocritical Care, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
| | - Melissa Chua
- Department of Neurosurgery, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
| | - Saef Izzy
- Department of Neurocritical Care, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
| | - Mohammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, 60 Fenwood Road, Boston, MA 02120, United States
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24
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Moreira TG, Matos KTF, De Paula GS, Santana TMM, Da Mata RG, Pansera FC, Cortina AS, Spinola MG, Keppeke GD, Jacob J, Palejwala V, Chen K, Izzy S, Healey BC, Rezende RM, Dedivitis RA, Shailubhai K, Weiner HL. Nasal Administration of Anti-CD3 Monoclonal Antibody (Foralumab) Reduces Lung Inflammation and Blood Inflammatory Biomarkers in Mild to Moderate COVID-19 Patients: A Pilot Study. Front Immunol 2021; 12:709861. [PMID: 34475873 PMCID: PMC8406802 DOI: 10.3389/fimmu.2021.709861] [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] [Received: 05/17/2021] [Accepted: 07/28/2021] [Indexed: 01/18/2023] Open
Abstract
Background Immune hyperactivity is an important contributing factor to the morbidity and mortality of COVID-19 infection. Nasal administration of anti-CD3 monoclonal antibody downregulates hyperactive immune responses in animal models of autoimmunity through its immunomodulatory properties. We performed a randomized pilot study of fully-human nasal anti-CD3 (Foralumab) in patients with mild to moderate COVID-19 to determine if its immunomodulatory properties had ameliorating effects on disease. Methods Thirty-nine outpatients with mild to moderate COVID-19 were recruited at Santa Casa de Misericordia de Santos in Sao Paulo State, Brazil. Patients were randomized to three cohorts: 1) Control, no Foralumab (n=16); 2) Nasal Foralumab (100ug/day) given for 10 consecutive days with 6 mg dexamethasone given on days 1-3 (n=11); and 3) Nasal Foralumab alone (100ug/day) given for 10 consecutive days (n=12). Patients continued standard of care medication. Results We observed reduction of serum IL-6 and C-reactive protein in Foralumab alone vs. untreated or Foralumab/Dexa treated patients. More rapid clearance of lung infiltrates as measured by chest CT was observed in Foralumab and Foralumab/Dexa treated subjects vs. those that did not receive Foralumab. Foralumab treatment was well-tolerated with no severe adverse events. Conclusions This pilot study suggests that nasal Foralumab is well tolerated and may be of benefit in treatment of immune hyperactivity and lung involvement in COVID-19 disease and that further studies are warranted.
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Affiliation(s)
- Thais G Moreira
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Kimble T F Matos
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | | | | | | | | | | | - Marcelle G Spinola
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Gerson D Keppeke
- Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jules Jacob
- Tiziana LifeScience, Doylestown, PA, United States
| | | | - Karen Chen
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, United States
| | - Saef Izzy
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Brian C Healey
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Rafael M Rezende
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | | | | | - Howard L Weiner
- Ann Romney Center for Neurologic Diseases, Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
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25
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Stopa BM, Tahir Z, Mezzalira E, Boaro A, Khawaja A, Grashow R, Zafonte RD, Smith TR, Gormley WB, Izzy S. The Impact of Age and Severity on Dementia After Traumatic Brain Injury: A Comparison Study. Neurosurgery 2021; 89:810-818. [PMID: 34392366 DOI: 10.1093/neuros/nyab297] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 12/10/2020] [Accepted: 06/07/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Growing evidence associates traumatic brain injury (TBI) with increased risk of dementia, but few studies have evaluated associations in patients younger than 55 yr using non-TBI orthopedic trauma (NTOT) patients as controls to investigate the influence of age and TBI severity, and to identify predictors of dementia after trauma. OBJECTIVE To investigate the relationship between TBI and dementia in an institutional group. METHODS Retrospective cohort study (2000-2018) of TBI patients aged 45 to 100 yr vs NTOT controls. Primary outcome was dementia after TBI (followed ≤10 yr). Cox proportional hazards models were used to assess risk of dementia; logistic regression models assessed predictors of dementia. RESULTS Among 24 846 patients, TBI patients developed dementia (7.5% vs 4.6%) at a younger age (78.6 vs 82.7 yr) and demonstrated higher 10-yr mortality than controls (27% vs 14%; P < .001). Mild TBI patients had higher incidence of dementia (9%) than moderate/severe TBI (5.4%), with lower 10-yr mortality (20% vs 31%; P < .001). Risk of dementia was significant in all mild TBI age groups, even 45 to 54 yr (hazard ratio 4.1, 95% CI 2.7-7.8). A total of 10-yr cumulative incidence was higher in mild TBI (14.4%) than moderate/severe TBI (11.3%) and controls (6.8%) (P < .001). Predictors of dementia include TBI, sex, age, hypertension, hyperlipidemia, stroke, depression, anxiety, and Injury Severity Score. CONCLUSION Mild and moderate/severe TBI patients experienced higher incidence of dementia, even in the youngest group (45-54 yr old), than NTOT controls. All TBI patients, especially middle-aged adults with minor injury who are more likely to be overlooked, should be monitored for dementia.
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Affiliation(s)
- Brittany M Stopa
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Zabreen Tahir
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Elisabetta Mezzalira
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alessandro Boaro
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, Universiy of Verona, Verona, Italy
| | - Ayaz Khawaja
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Neurology, Wayne State University, Detroit, Michigan, USA
| | - Rachel Grashow
- Department of Environmental Health, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.,Football Players Healthy Study at Harvard University, Harvard Medical School, Boston, Massachusetts, USA
| | - Ross D Zafonte
- Football Players Healthy Study at Harvard University, Harvard Medical School, Boston, Massachusetts, USA.,Department of Physical Medicine and Rehabilitation, Harvard Medical School, Spaulding Rehabilitation Hospital, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Timothy R Smith
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
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26
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Bianciardi M, Izzy S, Rosen BR, Wald LL, Edlow BL. Location of Subcortical Microbleeds and Recovery of Consciousness After Severe Traumatic Brain Injury. Neurology 2021; 97:e113-e123. [PMID: 34050005 PMCID: PMC8279563 DOI: 10.1212/wnl.0000000000012192] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/09/2021] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), coma is associated with impaired subcortical arousal mechanisms. However, it is unknown which nuclei involved in arousal (arousal nuclei) are implicated in coma pathogenesis and are compatible with coma recovery. METHODS We mapped an atlas of arousal nuclei in the brainstem, thalamus, hypothalamus, and basal forebrain onto 3 tesla susceptibility-weighted images (SWI) in 12 patients with acute severe TBI who presented in coma and recovered consciousness within 6 months. We assessed the spatial distribution and volume of SWI microbleeds and evaluated the association of microbleed volume with the duration of unresponsiveness and functional recovery at 6 months. RESULTS There was no single arousal nucleus affected by microbleeds in all patients. Rather, multiple combinations of microbleeds in brainstem, thalamic, and hypothalamic arousal nuclei were associated with coma and were compatible with recovery of consciousness. Microbleeds were frequently detected in the midbrain (100%), thalamus (83%), and pons (75%). Within the brainstem, the microbleed incidence was largest within the mesopontine tegmentum (e.g., pedunculotegmental nucleus, mesencephalic reticular formation) and ventral midbrain (e.g., substantia nigra, ventral tegmental area). Brainstem arousal nuclei were partially affected by microbleeds, with microbleed volume not exceeding 35% of brainstem nucleus volume on average. Compared to microbleed volume within nonarousal brainstem regions, the microbleed volume within arousal brainstem nuclei accounted for a larger proportion of variance in the duration of unresponsiveness and 6-month Glasgow Outcome Scale-Extended scores. CONCLUSION These results suggest resilience of arousal mechanisms in the human brain after severe TBI.
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Affiliation(s)
- Marta Bianciardi
- From the Department of Radiology, Athinoula A. Martinos Center for Biomedical Imaging (M.B., B.R.R., L.L.W., B.L.E.), and Center for Neurotechnology and Neurorecovery, Department of Neurology (B.L.E.), Massachusetts General Hospital and Harvard Medical School; Division of Sleep Medicine (M.B.), Harvard University; and Department of Neurology (S.I.), Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
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27
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Bernier TD, Schontz MJ, Izzy S, Chung DY, Nelson SE, Leslie-Mazwi TM, Henderson GV, Dasenbrock H, Patel N, Aziz-Sultan MA, Feske S, Du R, Abulhasan YB, Angle MR. Treatment of Subarachnoid Hemorrhage-associated Delayed Cerebral Ischemia With Milrinone: A Review and Proposal. J Neurosurg Anesthesiol 2021; 33:195-202. [PMID: 33480639 PMCID: PMC8192346 DOI: 10.1097/ana.0000000000000755] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 08/25/2020] [Accepted: 12/05/2020] [Indexed: 12/20/2022]
Abstract
Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage continues to be associated with high levels of morbidity and mortality. This complication had long been thought to occur secondary to severe cerebral vasospasm, but expert opinion now favors a multifactorial etiology, opening the possibility of new therapies. To date, no definitive treatment option for DCI has been recommended as standard of care, highlighting a need for further research into potential therapies. Milrinone has been identified as a promising therapeutic agent for DCI, possessing a mechanism of action for the reversal of cerebral vasospasm as well as potentially anti-inflammatory effects to treat the underlying etiology of DCI. Intra-arterial and intravenous administration of milrinone has been evaluated for the treatment of DCI in single-center case series and cohorts and appears safe and associated with improved clinical outcomes. Recent results have also brought attention to the potential outcome benefits of early, more aggressive dosing and titration of milrinone. Limitations exist within the available data, however, and questions remain about the generalizability of results across a broader spectrum of patients suffering from DCI. The development of a standardized protocol for milrinone use in DCI, specifically addressing areas requiring further clarification, is needed. Data generated from a standardized protocol may provide the impetus for a multicenter, randomized control trial. We review the current literature on milrinone for the treatment of DCI and propose a preliminary standardized protocol for further evaluation of both safety and efficacy of milrinone.
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Affiliation(s)
- Thomas D. Bernier
- Department of Pharmacy, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Saef Izzy
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David Y. Chung
- Harvard Medical School, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah E. Nelson
- Departments of Neurology and Anesthesiology & Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Thabele M. Leslie-Mazwi
- Harvard Medical School, Boston, MA, USA
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Galen V. Henderson
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Hormuzdiyar Dasenbrock
- Department of Neurosurgery, Boston Medical Center, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Nirav Patel
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Mohammad Ali Aziz-Sultan
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Steven Feske
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rose Du
- Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, MA, USA
| | - Yasser B. Abulhasan
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
- Faculty of Medicine, Health Sciences Center, Kuwait University, Kuwait
| | - Mark R. Angle
- Neurological Intensive Care Unit, Montreal Neurological Institute and Hospital, McGill University, Montreal, Quebec, Canada
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28
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Lule S, Wu L, Sarro-Schwartz A, Edmiston WJ, Izzy S, Songtachalert T, Ahn SH, Fernandes ND, Jin G, Chung JY, Balachandran S, Lo EH, Kaplan D, Degterev A, Whalen MJ. Cell-specific activation of RIPK1 and MLKL after intracerebral hemorrhage in mice. J Cereb Blood Flow Metab 2021; 41:1623-1633. [PMID: 33210566 PMCID: PMC8221773 DOI: 10.1177/0271678x20973609] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Receptor-interacting protein kinase-1 (RIPK1) is a master regulator of cell death and inflammation, and mediates programmed necrosis (necroptosis) via mixed-lineage kinase like (MLKL) protein. Prior studies in experimental intracerebral hemorrhage (ICH) implicated RIPK1 in the pathogenesis of neuronal death and cognitive outcome, but the relevant cell types involved and potential role of necroptosis remain unexplored. In mice subjected to autologous blood ICH, early RIPK1 activation was observed in neurons, endothelium and pericytes, but not in astrocytes. MLKL activation was detected in astrocytes and neurons but not endothelium or pericytes. Compared with WT controls, RIPK1 kinase-dead (RIPK1D138N/D138N) mice had reduced brain edema (24 h) and blood-brain barrier (BBB) permeability (24 h, 30 d), and improved postinjury rotarod performance. Mice deficient in MLKL (Mlkl-/-) had reduced neuronal death (24 h) and BBB permeability at 24 h but not 30d, and improved post-injury rotarod performance vs. WT. The data support a central role for RIPK1 in the pathogenesis of ICH, including cell death, edema, BBB permeability, and motor deficits. These effects may be mediated in part through the activation of MLKL-dependent necroptosis in neurons. The data support development of RIPK1 kinase inhibitors as therapeutic agents for human ICH.
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Affiliation(s)
- Sevda Lule
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Limin Wu
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Aliyah Sarro-Schwartz
- Department of Neurology, Brigham and Woman's Hospital, Harvard Medical School, Boston, MA, USA
| | - William J Edmiston
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Woman's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tanya Songtachalert
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - So Hee Ahn
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Neil D Fernandes
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Gina Jin
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Joon Yong Chung
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Siddharth Balachandran
- Blood Cell Development and Function Program, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eng H Lo
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA.,Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
| | - David Kaplan
- Department of Biomedical Engineering, Tufts University, Medford, MA, USA
| | - Alexei Degterev
- Department of Developmental, Molecular and Chemical Biology, Tufts University School of Medicine, Boston, MA, USA
| | - Michael J Whalen
- Department of Pediatrics, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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29
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Izzy S, Tahir Z, Grashow R, Cote DJ, Jarrah AA, Dhand A, Taylor H, Whalen M, Nathan DM, Miller KK, Speizer F, Baggish A, Weisskopf MG, Zafonte R. Concussion and Risk of Chronic Medical and Behavioral Health Comorbidities. J Neurotrauma 2021; 38:1834-1841. [PMID: 33451255 DOI: 10.1089/neu.2020.7484] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
While chronic neurological effects from concussion have been studied widely, little is known about possible links between concussion and long-term medical and behavioral comorbidities. We performed a retrospective cohort study of 9205 adult patients with concussion, matched to non-concussion controls from a hospital-based electronic medical registry. Patients with comorbidities before the index visit were excluded. Behavioral and medical comorbidities were defined by International Classification of Diseases, Ninth and Tenth Revision codes. Groups were followed for up to 10 years to identify comorbidity incidence after a concussion. Cox proportional hazards models were used to calculate associations between concussion and comorbidities after multi-variable adjustment. Patients with concussion were 57% male (median age: 31; interquartile range [IQR] = 23-48 years) at enrollment with a median follow-up time of 6.1 years (IQR = 4.2-9.1) and well-matched to healthy controls. Most (83%) concussions were evaluated in outpatient settings (5% inpatient). During follow-up, we found significantly higher risks of cardiovascular risks developing including hypertension (hazard ratio [HR] = 1.7, 95% confidence interval [CI]: 1.5-1.9), obesity (HR = 1.7, 95% CI: 1.3-2.0), and diabetes mellitus (HR = 1.8, 95% CI: 1.4-2.3) in the concussion group compared with controls. Similarly, psychiatric and neurological disorders such as depression (HR = 3.0, 95% CI: 2.6-3.5), psychosis (HR = 6.0, 95% CI: 4.2-8.6), stroke (HR = 2.1 95% CI: 1.5-2.9), and epilepsy (HR = 4.4, 95% CI: 3.2-5.9) were higher in the concussion group. Most comorbidities developed less than five years post-concussion. The risks for post-concussion comorbidities were also higher in patients under 40 years old compared with controls. Patients with concussion demonstrated an increased risk of development of medical and behavioral health comorbidities. Prospective studies are warranted to better describe the burden of long-term comorbidities in patients with concussion.
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Affiliation(s)
- Saef Izzy
- Department of Neurology, Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Zabreen Tahir
- Department of Neurology, Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rachel Grashow
- Department of Environmental Health, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.,The Football Players Health Study at Harvard University, Boston, Massachusetts, USA
| | - David J Cote
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Al Jarrah
- Department of Neurology, Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amar Dhand
- Department of Neurology, Divisions of Stroke, Cerebrovascular, and Critical Care Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Network Science Institute, Northeastern University, Boston, Massachusetts, USA
| | - Herman Taylor
- The Football Players Health Study at Harvard University, Boston, Massachusetts, USA.,Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Michael Whalen
- Department of Pediatrics, Cardiovascular Performance Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David M Nathan
- Harvard Medical School, Boston, Massachusetts, USA.,The Football Players Health Study at Harvard University, Boston, Massachusetts, USA.,Diabetes Center, Cardiovascular Performance Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Karen K Miller
- Harvard Medical School, Boston, Massachusetts, USA.,The Football Players Health Study at Harvard University, Boston, Massachusetts, USA.,Neuroendocrine Unit, Cardiovascular Performance Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Frank Speizer
- Department of Environmental Health, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Aaron Baggish
- Harvard Medical School, Boston, Massachusetts, USA.,The Football Players Health Study at Harvard University, Boston, Massachusetts, USA.,Department of Internal Medicine, Cardiovascular Performance Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marc G Weisskopf
- Department of Environmental Health, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA.,The Football Players Health Study at Harvard University, Boston, Massachusetts, USA
| | - Ross Zafonte
- Harvard Medical School, Boston, Massachusetts, USA.,The Football Players Health Study at Harvard University, Boston, Massachusetts, USA.,Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
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30
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Aldhaeefi M, Tahir Z, Cote DJ, Izzy S, El Khoury J. Comorbidities and Age Are Associated With Persistent COVID-19 PCR Positivity. Front Cell Infect Microbiol 2021; 11:650753. [PMID: 33889551 PMCID: PMC8056299 DOI: 10.3389/fcimb.2021.650753] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Received: 01/07/2021] [Accepted: 03/18/2021] [Indexed: 01/08/2023] Open
Abstract
Objectives The impact of demographics and comorbidities on the duration of COVID-19 nasopharyngeal swab PCR positivity remains unclear. The objective of our analysis is to determine the impact of age, intensive care unit (ICU) admission, comorbidities, and ethnicity on the duration of COVID-19 PCR positivity among hospitalized patients in a large group of hospital. Method We studied 530 patients from a large hospital system and time to SARS-CoV-2 virus RNA PCR negativity at any-time during hospitalization or following discharge from the hospital was the primary endpoint. We included patients 18 years or older who tested positive for COVID-19 during an inpatient, outpatient, or emergency room visit between February 1, 2020, and April 14, 2020. Results Overall, 315 (59.4%) of our patient population continued to have a positive SARS-CoV-2 virus RNA PCR 4 weeks after the initial positive test. We found that age>70 years, chronic kidney disease, hypertension, hyperlipidemia, obesity, or coronary artery disease are associated with persistent PCR positivity for more than 4 weeks after initial diagnosis. Conclusion Age, and the presence of co-morbidities should be taken into consideration when interpreting a positive COVID PCR test.
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Affiliation(s)
- Mohammed Aldhaeefi
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, MA, United States
| | - Zabreen Tahir
- Department of Neurology, Neurocritical Care, Brigham and Women's Hospital, Boston, MA, United States
| | - David J Cote
- Harvard Medical School, Boston, MA, United States
| | - Saef Izzy
- Department of Neurology, Neurocritical Care, Brigham and Women's Hospital, Boston, MA, United States.,Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Joseph El Khoury
- Department of Neurology, Neurocritical Care, Brigham and Women's Hospital, Boston, MA, United States.,Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, Boston, MA, United States.,Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, United States
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31
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DiRisio AC, Stopa BM, Pompeu YA, Vasudeva V, Khawaja AM, Izzy S, Gormley WB. Extra-Axial Fluid Collections After Decompressive Craniectomy: Management, Outcomes, and Treatment Algorithm. World Neurosurg 2021; 149:e188-e196. [PMID: 33639283 DOI: 10.1016/j.wneu.2021.02.052] [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: 11/17/2020] [Revised: 02/11/2021] [Accepted: 02/12/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Extra-axial fluid collections (EACs) frequently develop after decompressive craniectomy. Management of EACs remains poorly understood, and information on how to predict their clinical course is inadequate. We aimed to better characterize EACs, understand predictors of their resolution, and delineate the best treatment paradigm for patients. METHODS We reviewed patients who developed EACs after undergoing decompressive craniectomy for treatment of refractory intracranial pressure elevations. We excluded patients who had an ischemic stroke, as EACs in these patients have a different clinical course. We performed univariate analysis and multiple linear regression to find variables associated with earlier resolution of EACs and stratified our analyses by EAC phenotype (complicated vs. uncomplicated). We conducted a systematic review to compare our findings with the literature. RESULTS Of 96 included patients, 73% were male, and median age was 42.5 years. EACs resolved after a median of 60 days. Complicated EACs were common (62.5%) and required multiple drainage methods before cranioplasty. These were not associated with a protracted course or increased risk of death (P > 0.05). Early bone flap restoration with simultaneous drainage was independently associated with earlier resolution of EACs (β = 0.56, P < 0.001). Systematic review confirmed lack of standardized direction with respect to EAC management. CONCLUSIONS Our analyses reveal 2 clinically relevant phenotypes of EAC: complicated and uncomplicated. Our proposed treatment algorithm involves replacing the bone flap as soon as it is safe to do so and draining refractory EACs aggressively. Further studies to assess long-term clinical outcomes of EACs are warranted.
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Affiliation(s)
- Aislyn C DiRisio
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Brittany M Stopa
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
| | - Yuri A Pompeu
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Department of Orthopedics, Hospital for Special Surgery, New York, New York, USA
| | - Viren Vasudeva
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Ayaz M Khawaja
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Saef Izzy
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA; Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - William B Gormley
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA
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32
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Chua MMJ, Gupta S, Essayed WI, Donnelly DJ, Ziayee H, Vicenty-Padilla J, Das AS, Lai RPM, Izzy S, Aziz-Sultan MA. Endovascular treatment of a ruptured posterior fossa pure arterial malformation: illustrative case. J Neurosurg Case Lessons 2021; 1:CASE2073. [PMID: 35854927 PMCID: PMC9241320 DOI: 10.3171/case2073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 10/17/2020] [Accepted: 10/30/2020] [Indexed: 06/15/2023]
Abstract
BACKGROUND Pure arterial malformations (PAMs) are rare vascular anomalies that are commonly mistaken for other vascular malformations. Because of their purported benign natural history, PAMs are often conservatively managed. The authors report the case of a ruptured PAM leading to subarachnoid hemorrhage (SAH) with intraventricular extension that was treated endovascularly. OBSERVATIONS A 38-year-old man presented with a 1-day history of headaches and nausea. A computed tomography scan demonstrated diffuse SAH with intraventricular extension, and angiography revealed a right posterior inferior cerebellar artery-associated PAM. The PAM was treated with endovascular Onyx embolization. LESSONS To the authors' knowledge, only 2 other cases of SAH associated with PAM have been reported. In those 2 cases, surgical clipping was pursued for definitive treatment. Here, the authors report the first case of a ruptured PAM treated using an endovascular approach, showing its feasibility as a treatment option particularly in patients in whom open surgery is too high a risk.
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Affiliation(s)
| | | | | | | | | | | | - Alvin S. Das
- Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Saef Izzy
- Neurology, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
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33
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Das AS, Regenhardt RW, Patel N, Feske SK, Bevers MB, Vaitkevicius H, Izzy S. Diffuse Cerebral Edema After Moyamoya Disease-Related Intracerebral Hemorrhage: A Case Report. Neurohospitalist 2020; 11:251-254. [PMID: 34163552 DOI: 10.1177/1941874420980611] [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: 11/16/2022] Open
Abstract
Moyamoya disease (MMD) is a rare, progressive occlusive disease characterized by bilateral internal carotid artery hypoplasia that often presents with ischemic stroke and intracerebral hemorrhage (ICH). Although MMD-related ICH is generally managed similarly to spontaneous ICH, we present a case in which standard management strategies may have led to an unprecedented devastating outcome. A 37-year-old female without any previous medical history presented with headache and right-sided weakness. A computed tomography (CT) scan revealed a large left basal ganglia ICH. Vessel imaging revealed diffuse narrowing of the entire anterior circulation with prominent leptomeningeal collaterals consistent with MMD. The patient's systolic blood pressure was kept under 140 mmHg. During the hospitalization, she became hypocarbic while being trialed on pressure support ventilation. Several hours later, she developed fixed and dilated pupils. Repeat CT head showed new diffuse cerebral edema with tonsillar herniation. Despite hyperosmolar therapy, paralytics, pentobarbital, and cerebrospinal fluid diversion, no improvement was noted. Unfortunately, brain MRI revealed multifocal brainstem infarcts with superimposed Duret hemorrhages. Herein, we report diffuse cerebral edema as a complication of MMD-related ICH. We hypothesize that disruptions of delicate cerebral autoregulatory mechanisms led to extensive hypoxic-ischemic injury. In the setting of ICH, aggressive blood pressure management coupled with relative hypocapnia may have likely caused vasoconstriction of poorly compliant arteries leading to worsened cerebral blood flow and ischemia. Therefore, because of its complex pathophysiology, strict adherence to eucapnia should be maintained in MMD-related ICH.
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Affiliation(s)
- Alvin S Das
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nirav Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Steven K Feske
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew B Bevers
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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DiRisio A, Stopa BM, Pompeu YA, Vasudeva V, Khawaja A, Izzy S, Gormley W. Management of Extra-Axial Fluid Collections After Decompressive Craniectomy. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_424] [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: 11/14/2022] Open
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Chua MMJ, Das AS, Losman JA, Patel NJ, Izzy S. Spontaneous hemorrhage after external ventricular drain placement in the setting of low factor VII secondary to liver cirrhosis. Surg Neurol Int 2020; 11:403. [PMID: 33365166 PMCID: PMC7749959 DOI: 10.25259/sni_446_2020] [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] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 11/06/2020] [Indexed: 12/05/2022] Open
Abstract
Background: Alterations in normal coagulation and hemostasis are critical issues that require special attention in the neurosurgical patient. These disorders pose unique challenges in the management of these patients who often have concurrent acute ischemic and hemorrhagic injuries. Although neurosurgical intervention in such cases may be unavoidable and potentially life-saving, these patients should be closely observed after instrumentation. Case Description: A 57-year-old male with liver cirrhosis secondary to amyloid light-chain amyloidosis was admitted to the intensive care unit for the management of delayed hydrocephalus. An external ventricular drain (EVD) was placed for the treatment and monitoring of hydrocephalus. Five days after EVD placement, a head computed tomography scan revealed a tract hemorrhage. However, on repeated imaging, the size of the hemorrhage continued to increase despite aggressive blood pressure control and several doses of phytonadione. Extensive coagulopathy workup was remarkable for low factor VII levels. In that setting, recombinant activated factor VII was administered to normalize factor VII levels, and the tract hemorrhage stabilized. Conclusion: To the best of our knowledge, this is the first case of spontaneous hemorrhage after EVD placement in the setting of liver cirrhosis-associated factor VII deficiency. Our case highlights the importance of identifying coagulation disorders in neurosurgical patients at high risk for coagulopathy and closely monitoring them postoperatively.
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Affiliation(s)
- Melissa Ming Jie Chua
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Alvin S Das
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Julie Aurore Losman
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, United States
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, United States
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Stopa BM, Harary M, Jhun R, Job A, Izzy S, Smith TR, Gormley WB. Divergence in the epidemiological estimates of traumatic brain injury in the United States: comparison of two national databases. J Neurosurg 2020; 135:584-593. [PMID: 33254146 DOI: 10.3171/2020.7.jns201896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 05/19/2020] [Accepted: 07/06/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in the US, but the true incidence of TBI is unknown. METHODS The National Trauma Data Bank National Sample Program (NTDB NSP) was queried for 2007 and 2013, and population-based weighted estimates of TBI-related emergency department (ED) visits, hospitalizations, and deaths were calculated. These data were compared to the 2017 Centers for Disease Control and Prevention (CDC) report on TBI, which used the Healthcare Cost and Utilization Project's National ("Nationwide" before 2012) Inpatient Sample and National Emergency Department Sample. RESULTS In the NTDB NSP the incidence of TBI-related ED visits was 59/100,000 in 2007 and 62/100,000 in 2013. However, in the CDC report there were 534/100,000 in 2007 and 787/100,000 in 2013. The CDC estimate for ED visits was 805% higher in 2007 and 1169% higher in 2013. In the NTDB NSP, the incidence of TBI-related deaths was 5/100,000 in 2007 and 4/100,000 in 2013. In the CDC report, the incidence was 18/100,000 in both years. The CDC estimate for deaths was 260% higher in 2007 and 325% higher in 2013. CONCLUSIONS The databases disagreed widely in their weighted estimates of TBI incidence: CDC estimates were consistently higher than NTDB NSP estimates, by an average of 448%. Although such a discrepancy may be intuitive, this is the first study to quantify the magnitude of disagreement between these databases. Given that research, funding, and policy decisions are made based on these estimates, there is a need for a more accurate estimate of the true national incidence of TBI.
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Affiliation(s)
- Brittany M Stopa
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 2Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Maya Harary
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 3Department of Neurosurgery, University of California, Los Angeles, California
| | - Ray Jhun
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 4Boston University School of Medicine, Boston; and
| | - Arun Job
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
- 4Boston University School of Medicine, Boston; and
| | - Saef Izzy
- 5Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - William B Gormley
- 1Computational Neuroscience Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Izzy S, Tahir Z, Cote DJ, Al Jarrah A, Roberts MB, Turbett S, Kadar A, Smirnakis SM, Feske SK, Zafonte R, Fishman JA, El Khoury J. Characteristics and Outcomes of Latinx Patients With COVID-19 in Comparison With Other Ethnic and Racial Groups. Open Forum Infect Dis 2020; 7:ofaa401. [PMID: 33088846 PMCID: PMC7499713 DOI: 10.1093/ofid/ofaa401] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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: 08/03/2020] [Accepted: 08/26/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND There is a limited understanding of the impact of coronavirus disease 2019 (COVID-19) on the Latinx population. We hypothesized that Latinx patients would be more likely to be hospitalized and admitted to the intensive care unit (ICU) than White patients. METHODS We analyzed all patients with COVID-19 in 12 Massachusetts hospitals between February 1 and April 14, 2020. We examined the association between race, ethnicity, age, reported comorbidities, and hospitalization and ICU admission using multivariable regression. RESULTS Of 5190 COVID-19 patients, 29% were hospitalized; 33% required the ICU, and 4.3% died. Forty-six percent of patients were White, 25% Latinx, 14% African American, and 3% Asian American. Ethnicity and race were significantly associated with hospitalization. More Latinx and African American patients in the younger age groups were hospitalized than whites. Latinxs and African Americans disproportionally required the ICU, with 39% of hospitalized Latinx patients requiring the ICU compared with 33% of African Americans, 24% of Asian Americans, and 30% of Whites (P < .007). Within each ethnic and racial group, age and male gender were independently predictive of hospitalization. Previously reported preexisting comorbidities contributed to the need for hospitalization in all racial and ethnic groups (P < .05). However, the observed disparities were less likely related to reported comorbidities, with Latinx and African American patients being admitted at twice the rate of Whites, regardless of such comorbidities. CONCLUSIONS Latinx and African American patients with COVID-19 have higher rates of hospitalization and ICU admission than White patients. The etiologies of such disparities are likely multifactorial and cannot be explained only by reported comorbidities.
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Affiliation(s)
- Saef Izzy
- Department of Neurology, Neurocritical Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Zabreen Tahir
- Department of Neurology, Neurocritical Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - David J Cote
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Al Jarrah
- Department of Neurology, Neurocritical Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Matthew Blake Roberts
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sarah Turbett
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aran Kadar
- Department of Medicine, Division of Pulmonary Critical Care, Newton Wellesley Hospital, Newton, Massachusetts
| | - Stelios M Smirnakis
- Department of Neurology, Neurocritical Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Steven K Feske
- Department of Neurology, Neurocritical Care, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ross Zafonte
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Physical Medicine and Rehabilitation Massachusetts General Hospital, Boston, Massachusetts, USA
- Spaulding Rehabilitation Hospital, Charlestown, Massachusetts, USA
| | - Jay A Fishman
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph El Khoury
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medicine, Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
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Otite FO, Patel S, Sharma R, Khandwala P, Desai D, Latorre JG, Akano EO, Anikpezie N, Izzy S, Malik AM, Yavagal D, Khandelwal P, Chaturvedi S. Trends in incidence and epidemiologic characteristics of cerebral venous thrombosis in the United States. Neurology 2020; 95:e2200-e2213. [PMID: 32847952 DOI: 10.1212/wnl.0000000000010598] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 05/12/2020] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To test the hypothesis that race-, age-, and sex-specific incidence of cerebral venous thrombosis (CVT) has increased in the United States over the last decade. METHODS In this retrospective cohort study, validated ICD codes were used to identify all new cases of CVT (n = 5,567) in the State Inpatients Databases (SIDs) of New York and Florida (2006-2016). A new CVT case was defined as first hospitalization for CVT in the SID without prior CVT hospitalization. CVT counts were combined with annual Census data to compute incidence. Joinpoint regression was used to evaluate trends in incidence over time. RESULTS From 2006 to 2016, annual age- and sex-standardized incidence of CVT in cases per 1 million population ranged from 13.9 to 20.2, but incidence varied significantly by sex (women 20.3-26.9, men 6.8-16.8) and by age/sex (women 18-44 years of age 24.0-32.6, men 18-44 years of age 5.3-12.8). Incidence also differed by race (Blacks: 18.6-27.2; Whites: 14.3-18.5; Asians: 5.1-13.8). On joinpoint regression, incidence increased across 2006 to 2016, but most of this increase was driven by an increase in all age groups of men (combined annualized percentage change [APC] 9.2%, p < 0.001), women 45 to 64 years of age (APC 7.8%, p < 0.001), and women ≥65 years of age (APC 7.4%, p < 0.001). Incidence in women 18 to 44 years of age remained unchanged over time. CONCLUSION CVT incidence is disproportionately higher in Blacks compared to other races. New CVT hospitalizations increased significantly over the last decade mainly in men and older women. Further studies are needed to determine whether this increase represents a true increase from changing risk factors or an artifactual increase from improved detection.
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Affiliation(s)
- Fadar Oliver Otite
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore.
| | - Smit Patel
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Richa Sharma
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Pushti Khandwala
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Devashish Desai
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Julius Gene Latorre
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Emmanuel Oladele Akano
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Nnabuchi Anikpezie
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Saef Izzy
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Amer M Malik
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Dileep Yavagal
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Priyank Khandelwal
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
| | - Seemant Chaturvedi
- From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore
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Roberts MB, Izzy S, Tahir Z, Al Jarrah A, Fishman JA, El Khoury J. COVID-19 in solid organ transplant recipients: Dynamics of disease progression and inflammatory markers in ICU and non-ICU admitted patients. Transpl Infect Dis 2020; 22:e13407. [PMID: 32654303 PMCID: PMC7404585 DOI: 10.1111/tid.13407] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [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] [Received: 06/30/2020] [Accepted: 07/05/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND COVID-19 infection varies in severity from minimal symptoms to critical illness associated with a hyperinflammatory response. Data on disease progression in immunosuppressed solid organ transplant (SOT) recipients are limited. METHODS We examined the electronic medical records of all SOT recipients with COVID-19 from 12 Massachusetts hospitals between February 1, and May 6, 2020. We analyzed the demographics, clinical parameters, course, and outcomes of illness in these patients. RESULTS Of 52 COVID-19-positive SOT patients, 77% were hospitalized and 35% required ICU admission. Sixty-nine percent of hospitalized patients had immunosuppression reduced, 6% developed suspected rejection. Co-infections occurred in 45% in ICU vs 5% in non-ICU patients (P = .037). A biphasic pattern of evolution of laboratory tests was observed. In the first 5 days of illness, inflammatory markers were moderately increased. Subsequently, WBC, CRP, ferritin, and D Dimer increased with increasing stay in the ICU, and lymphocyte counts were similar. Five patients (16%) died. CONCLUSIONS Our data indicate that SOT is associated with high rate of hospitalization, ICU admission, and death from COVID-19 compared to data in the general population of patients with COVID-19. Despite reduction in immunosuppression, suspected rejection was rare. The clinical course and trend of laboratory biomarkers is biphasic with a later, pronounced peak in inflammatory markers seen in those admitted to an ICU. CRP is a useful marker to monitor disease progression in SOT.
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Affiliation(s)
- Matthew B Roberts
- Division of Infectious Diseases, Department of Medicine and MGH Transplant Centre, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Saef Izzy
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Neurocritical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Zabreen Tahir
- Department of Neurology, Neurocritical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ali Al Jarrah
- Department of Neurology, Neurocritical Care, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Joseph El Khoury
- Division of Infectious Diseases, Department of Medicine and MGH Transplant Centre, Massachusetts General Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
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40
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Otite F, Patel S, Sharma R, Khandwala P, Desai D, Latorre J, Izzy S, Akano E, Anikpezie N, Malik A, Khandelwal P, Yavagal D, Chaturvedi S. Abstract WMP60: Temporal Trends in Incidence, Prevalence and Epidemiological Characteristics of Cerebral Venous Thrombosis in the United States. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wmp60] [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] [Indexed: 11/16/2022]
Abstract
Background:
The primary aim of this study is to describe current trends in racial-, age- and sex-specific incidence, clinical characteristics and burden of cerebral venous thrombosis (CVT) in the United States (US).
Methods:
Validated International Classification of Disease codes were used to identify all adult new cases of CVT (n=5,567) in the State Inpatients Database of New York and Florida (2006-2016) and all cases of CVT in the entire US from the National Inpatient Sample 2005-2016 (weighted n=57,315). Incident CVT counts were combined with annual US Census data to compute age and sex-specific incidence of CVT. Joinpoint regression was used to evaluate trends in incidence over time.
Results:
From 2005-2016, 0.47%-0.80% of all strokes in the US were CVTs but this proportion increased by 70.4% over time. Of all CVTs over this period, 66.7% were in females but this proportion declined over time (p<0.001). Pregnancy/puerperium (27.4%) and cancer (11.8%) were the most common risk factors in women, while cancer (19.5%) and central nervous trauma (11.3) were the most common in men. Whereas the prevalence of pregnancy/puerperium declined significantly over time in women, that of cancer, inflammatory conditions and trauma increased over time in both sexes. Annual age and sex-standardized incidence of CVT in cases/million population ranged from 13.9-20.2, but incidence varied significantly by sex (women: 20.3-26.9; men 6.8-16.8) and by age/sex (women 18-44yo: 24.0-32.6%; men: 18-44yo: 5.3-12.8). Age and sex-standardized incidence also differed by race (Blacks:18.6-27.2; whites: 14.3-18.5; Asians: 5.1-13.8). On joinpoint regression, incidence increased across 2006-2016 but most of this increase was driven by increase in all age groups of men (combined annualized percentage change (APC) 9.2%, p-value <0.001), women 45-64 yo (APC 7.8%, p-value <0.001) and women ≥65 yo (APC 7.4%, p-value <0.001). Incidence in women 18-44 yo remained unchanged over time .
Conclusion:
The epidemiological characteristics of CVT patients in the US is changing. Incidence increased significantly over the last decade. Further studies are needed to determine whether this increase represents a true increase from changing risk factors or artefactual increase from improved detection.
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Affiliation(s)
| | | | | | | | | | | | - Saef Izzy
- Neurology, Brigham and Women’s Hosp, Boston, MA
| | | | | | - Amer Malik
- Univ of Miami Miller Sch of Medicine, Miami, FL
| | | | - Dileep Yavagal
- Neurology, Univ of Miami Miller Sch of Medicine, Miami, FL
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Wu L, Chung JY, Saith S, Tozzi L, Buckley EM, Sanders B, Franceschini MA, Lule S, Izzy S, Lok J, Edmiston WJ, McAllister LM, Mebane S, Jin G, Lu J, Sherwood JS, Willwerth S, Hickman S, Khoury JE, Lo EH, Kaplan D, Whalen MJ. Repetitive head injury in adolescent mice: A role for vascular inflammation. J Cereb Blood Flow Metab 2019; 39:2196-2209. [PMID: 30001646 PMCID: PMC6827111 DOI: 10.1177/0271678x18786633] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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] [Indexed: 12/14/2022]
Abstract
Repetitive mild traumatic brain injury during adolescence can induce neurological dysfunction through undefined mechanisms. Interleukin-1 (IL-1) contributes to experimental adult diffuse and contusion TBI models, and IL-1 antagonists have entered clinical trials for severe TBI in adults; however, no such data exist for adolescent TBI. We developed an adolescent mouse repetitive closed head injury (rCHI) model to test the role of IL-1 family members in post-injury neurological outcome. Compared to one CHI, three daily injuries (3HD) produced acute and chronic learning deficits and emergence of hyperactivity, without detectable gliosis, neurodegeneration, brain atrophy, and white matter loss at one year. Mature IL-1β and IL-18 were induced in brain endothelium in 3HD but not 1HD, three hit weekly, or sham animals. IL-1β processing was induced cell-autonomously in three-dimensional human endothelial cell cultures subjected to in vitro concussive trauma. Mice deficient in IL-1 receptor-1 or caspase-1 had improved post-injury Morris water maze performance. Repetitive mild CHI in adolescent mice may induce behavioral deficits in the absence of significant histopathology. The endothelium is a potential source of IL-1β and IL-18 in rCHI, and IL-1 family members may be therapeutic targets to reduce or prevent neurological dysfunction after repetitive mild TBI in adolescents.
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Affiliation(s)
- Limin Wu
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Joon Y Chung
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Shivani Saith
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Lorenzo Tozzi
- Department of Biomedical Engineering, Tufts University, Medford, MA, USA
| | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA.,Department of Pediatrics, Emory University, Atlanta, GA, USA
| | - Bharat Sanders
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
| | | | - Sevda Lule
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Josephine Lok
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - William J Edmiston
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Lauren M McAllister
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Sloane Mebane
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Gina Jin
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Jiaxi Lu
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - John S Sherwood
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Sarah Willwerth
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Suzanne Hickman
- Department of Medicine, Center for Immunology and Inflammatory Diseases, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Joseph El Khoury
- Department of Medicine, Center for Immunology and Inflammatory Diseases, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Eng H Lo
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.,Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - David Kaplan
- Department of Biomedical Engineering, Tufts University, Medford, MA, USA
| | - Michael J Whalen
- Neuroscience Center, Harvard Medical School, Massachusetts General Hospital, Charlestown, MA, USA.,Department of Pediatrics, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
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Mezzalira E, Stopa B, Khawaja A, Izzy S, Gormley W. Traumatic brain injury as a risk factor for dementia. Eur J Public Health 2019. [DOI: 10.1093/eurpub/ckz185.146] [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] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
The Centers for Disease Control and Prevention (CDC) reports that there were 2.87 million cases of traumatic brain injury (TBI) in the United States in 2014, 69 million worldwide. Some studies suggest a connection between TBI and increased risk of dementia, but it remains unclear whether the risk increases with age and TBI severity. Given our aging population, it is essential to better characterize the link between TBI and dementia.
Methods
We conducted a retrospective cohort study of two major academic medical centers for years 2000-2015. We identified all patients with TBI, aged 45 and older. Variables included age, TBI severity, pre-existing dementia, dementia diagnosed after TBI, years to dementia, and follow-up time. TBI severity was determined by head/neck AIS score, using ICD-PIC software. Mild TBI was defined as AIS 0-2, and Moderate/Severe as AIS 3-6. Analysis was done in R.v.3.0.1 software.
Results
Overall, there were 14,199 patients with TBI, of which 9,938 (70%) were mild and 4,261 (30%) were moderate/severe. Mean age was 70.5 (±14.0). There were 1,422 cases (10%) of pre-existing dementia, and 850 (6%) cases of dementia diagnosed after TBI. The mean follow-up time was 1,129 (±1,474) days.
The 75-84 age group had the highest incidence of TBI (28%). When compared by age group and TBI severity, the proportion of moderate/severe TBI increased with increasing age. The proportion of pre-existing dementia increased with age, as expected. Notably, there is increased incidence of dementia after TBI in patients aged 65 and older (7-10%, p < 0.001). There was no observed effect of TBI severity on the risk of dementia after TBI.
Conclusions
Our results indicate that TBI is a risk factor for the development of dementia, especially in patients aged 65 and older. Given the global public health burden of these two diseases it is critical to develop effective TBI primary prevention strategies.
Key messages
TBI is a risk factor for the development of dementia. Need for public health measures to mitigate the risk of TBI in the patient population 65 and older.
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Affiliation(s)
- E Mezzalira
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women’s Hospital, Boston, USA
| | - B Stopa
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women’s Hospital, Boston, USA
| | - A Khawaja
- Department of Neurology, Brigham and Women’s Hospital, Boston, USA
| | - S Izzy
- Department of Neurology, Brigham and Women’s Hospital, Boston, USA
| | - W Gormley
- Computational Neuroscience Outcomes Center at Harvard, Brigham and Women’s Hospital, Boston, USA
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Gupta S, Hauser BM, Zaki MM, Cote DJ, Izzy S, Smith TR, Khawaja AM. Firearm Injuries Cause Disproportionate Mortality in Pediatric Traumatic Brain Injury. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_340] [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: 11/12/2022] Open
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44
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Stopa BM, Mezzalira E, Khawaja A, Izzy S, Gormley WB. Traumatic Brain Injury as a Risk Factor for Dementia: An Eighteen-Year Two Institution Clinical Experience. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
INTRODUCTION
The Centers for Disease Control and Prevention (CDC) reports that there were 2.87 million cases of traumatic brain injury (TBI) in the United States in 2014. Some studies suggest a connection between TBI and increased risk of dementia, but it remains unclear whether the risk increases with age and TBI severity. Given our aging population, it is essential to better characterize the link between TBI and dementia.
METHODS
We conducted a retrospective cohort study of 2 major academic medical centers for years 2000 to 2015. We identified all patients with TBI, aged 45 and older. Variables included age, TBI severity, pre-existing dementia, dementia diagnosed after TBI, years to dementia, and follow-up time. TBI severity was determined by head/neck AIS score, using ICD-PIC software. Mild TBI was defined as AIS 0 to 2, and moderate/severe as AIS 3 to 6. Analysis was done in R.v.3.0.1 software.
RESULTS
Overall, there were 14 199 patients with TBI, of which 9938 (70%) were mild and 4261 (30%) were moderate/severe. Mean age was 70.5 (± 14.0). There were 1422 cases (10%) of pre-existing dementia, and 850 (6%) cases of dementia diagnosed after TBI. The mean follow-up time was 1129 (± 1,474) d. The 75 to 84 age group had the highest incidence of TBI (28%). When compared by age group and TBI severity, the proportion of moderate/severe TBI increased with increasing age. The proportion of pre-existing dementia increased with age, as expected. Notably, there is increased incidence of dementia after TBI in patients aged 65 and older (7%-10%, P < .001). There was no observed effect of TBI severity on the risk of dementia after TBI.
CONCLUSION
Our results indicate that TBI is a risk factor for the development of dementia, especially in patients aged 65 and older. This points to the need for public health measures to mitigate the risk of TBI in this patient population.
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Cohen AS, Izzy S, Kumar MA, Joyce CJ, Figueroa SA, Maas MB, Hall CE, McDonagh DL, Lerner DP, Vespa PM, Shutter LA, Rosenthal ES. Education Research: Variation in priorities for neurocritical care education expressed across role groups. Neurology 2019; 90:1117-1122. [PMID: 29891575 DOI: 10.1212/wnl.0000000000005682] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To define expectations for neurocritical care (NCC) core competencies vs competencies considered within the domain of other subspecialists. METHODS An electronic survey was disseminated nationally to NCC nurses, physicians, fellows, and neurology residents through Accreditation Council for Graduate Medical Education neurology residency program directors, United Council for Neurologic Subspecialties neurocritical care fellowship program directors, and members of the Neurocritical Care Society. RESULTS A total of 268 neurocritical care providers and neurology residents from 30 institutions responded. Overall, >90% supported NCC graduates independently interpreting and managing systemic and cerebral hemodynamic data, or performing brain death determination, neurovascular ultrasound, vascular access, and airway management. Over 75% endorsed that NCC graduates should independently interpret EEG and perform bronchoscopies. Fewer but substantial respondents supported graduates being independent performing intracranial bolt (45.8%), ventriculostomy (39.0%), tracheostomy (39.8%), or gastrostomy (19.1%) procedures. Trainees differed from physicians and program directors, respectively, by advocating independence in EEG interpretation (92.8%, 61.8%, and 65.3%) and PEG placement (29.3%, 9.1%, and 8.5%). CONCLUSIONS Broad support exists across NCC role groups for wide-ranging NCC competencies including skills often performed by other neurology and non-neurology subspecialties. Variations highlight natural divergences in expectations among trainee, physician, and nurse role groups. These results establish expectations for core competencies within NCC and initiate dialogue across subspecialties about best practice standards for the spectrum of critically ill patients requiring neurologic care.
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Affiliation(s)
- Abigail S Cohen
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Saef Izzy
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Monisha A Kumar
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Cara J Joyce
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Stephen A Figueroa
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Matthew B Maas
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Christiana E Hall
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - David L McDonagh
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - David P Lerner
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Paul M Vespa
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Lori A Shutter
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston
| | - Eric S Rosenthal
- From Tulane University School of Medicine (A.S.C.), New Orleans, LA; Department of Neurology (S.I.), Brigham and Women's Hospital, Boston, MA; Department of Neurology (M.A.K.), University of Pennsylvania, Philadelphia; Department of Public Health Sciences (C.J.J.), Loyola University, Chicago, IL; Departments of Neurology and Neurotherapeutics (S.A.F., C.E.H.) and Anesthesiology, Neurology, and Neurosurgery (D.L.M.), UT Southwestern, Dallas, TX; Department of Neurology (M.B.M.), Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Neurology (D.P.L.), Lahey Clinic, Burlington, MA; Departments of Neurology and Neurosurgery (P.M.V.), David Geffen School of Medicine at UCLA, Los Angeles, CA; Departments of Critical Care Medicine, Neurology & Neurosurgery (L.A.S.), University of Pittsburgh School of Medicine/UPMC, PA; and Department of Neurology (E.S.R.), Massachusetts General Hospital, Boston.
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Izzy S, Liu Q, Fang Z, Lule S, Wu L, Chung JY, Sarro-Schwartz A, Brown-Whalen A, Perner C, Hickman SE, Kaplan DL, Patsopoulos NA, El Khoury J, Whalen MJ. Time-Dependent Changes in Microglia Transcriptional Networks Following Traumatic Brain Injury. Front Cell Neurosci 2019; 13:307. [PMID: 31440141 PMCID: PMC6694299 DOI: 10.3389/fncel.2019.00307] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [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] [Received: 03/05/2019] [Accepted: 06/24/2019] [Indexed: 12/21/2022] Open
Abstract
The neuroinflammatory response to traumatic brain injury (TBI) is critical to both neurotoxicity and neuroprotection, and has been proposed as a potentially modifiable driver of secondary injury in animal and human studies. Attempts to broadly target immune activation have been unsuccessful in improving outcomes, in part because the precise cellular and molecular mechanisms driving injury and outcome at acute, subacute, and chronic time points after TBI remain poorly defined. Microglia play a critical role in neuroinflammation and their persistent activation may contribute to long-term functional deficits. Activated microglia are characterized by morphological transformation and transcriptomic changes associated with specific inflammatory states. We analyzed the temporal course of changes in inflammatory genes of microglia isolated from injured brains at 2, 14, and 60 days after controlled cortical impact (CCI) in mice, a well-established model of focal cerebral contusion. We identified a time dependent, injury-associated change in the microglial gene expression profile toward a reduced ability to sense tissue damage, perform housekeeping, and maintain homeostasis in the early stages following CCI, with recovery and transition to a specialized inflammatory state over time. This later state starts at 14 days post-injury and is characterized by a biphasic pattern of IFNγ, IL-4, and IL-10 gene expression changes, with concurrent proinflammatory and anti-inflammatory gene changes. Our transcriptomic data sets are an important step to understand microglial role in TBI pathogenesis at the molecular level and identify common pathways that affect outcome. More studies to evaluate gene expression at the single cell level and focusing on subacute and chronic timepoint are warranted.
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Affiliation(s)
- Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Qiong Liu
- Department of Anatomy, Histology and Embryology, School of Basic Medical Sciences, Fudan University, Shanghai, China.,Shanghai Key Laboratory of Medical Imaging Computing and Computer Assisted Intervention, Shanghai, China
| | - Zhou Fang
- Harvard Medical School, Boston, MA, United States.,Systems Biology and Computer Science Program, Ann Romney Center for Neurological Diseases, Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States.,Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Sevda Lule
- Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Limin Wu
- Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Joon Yong Chung
- Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aliyah Sarro-Schwartz
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Alexander Brown-Whalen
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States
| | - Caroline Perner
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Suzanne E Hickman
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - David L Kaplan
- Department of Biomedical Engineering, Tufts University, Medford, MA, United States
| | - Nikolaos A Patsopoulos
- Harvard Medical School, Boston, MA, United States.,Systems Biology and Computer Science Program, Ann Romney Center for Neurological Diseases, Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States.,Division of Genetics, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States.,Broad Institute of Harvard and Massachusetts Institute of Technology, Cambridge, MA, United States
| | - Joseph El Khoury
- Center for Immunology and Inflammatory Diseases, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.,Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Harvard Medical School, Boston, MA, United States
| | - Michael J Whalen
- Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, United States.,Harvard Medical School, Boston, MA, United States.,Department of Pediatrics, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
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Barra ME, Izzy S, Sarro-Schwartz A, Hirschberg RE, Mazwi N, Edlow BL. Stimulant Therapy in Acute Traumatic Brain Injury: Prescribing Patterns and Adverse Event Rates at 2 Level 1 Trauma Centers. J Intensive Care Med 2019; 35:1196-1202. [PMID: 30966863 DOI: 10.1177/0885066619841603] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [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: 11/17/2022]
Abstract
BACKGROUND/OBJECTIVE Pharmacological stimulant therapies are routinely administered to promote recovery in patients with subacute and chronic disorders of consciousness (DoC). However, utilization rates and adverse drug event (ADE) rates of stimulant therapies in patients with acute DoC are unknown. We aimed to determine the frequency of stimulant use and associated ADEs in intensive care unit (ICU) patients with acute DoC caused by traumatic brain injury (TBI). METHODS We retrospectively identified patients with TBI admitted to the ICU at 2 level 1 trauma centers between 2015 and 2018. Patients were included if they were stimulant naive at baseline and received amantadine, methylphenidate, or modafinil during ICU admission. Stimulant dose reduction or discontinuation during ICU admission was considered a surrogate marker of an ADE. Targeted chart review was performed to identify reasons for dose reduction or discontinuation. RESULTS Forty-eight of 608 patients with TBI received pharmacological stimulant therapy (7.9%) during the study period. Most patients were diagnosed with severe TBI at presentation (60.4%), although stimulants were also administered to patients with moderate (14.6%) and mild (25.0%) TBI. The median time of stimulant initiation was 11 days post-injury (range: 2-28 days). Median Glasgow Coma Scale score at the time of stimulant initiation was 9 (range: 4-15). Amantadine was the most commonly prescribed stimulant (85.4%) followed by modafinil (14.6%). Seven (14.6%) patients required stimulant dose reduction or discontinuation during ICU admission. The most common ADE resulting in therapy modification was delirium/agitation (n = 2), followed by insomnia (n = 1), anxiety (n = 1), and rash (n = 1); the reason for therapy modification was undocumented in 2 patients. CONCLUSIONS Pharmacological stimulant therapy is infrequently prescribed but well tolerated in ICU patients with acute TBI at level 1 trauma centers. These retrospective observations provide the basis for prospective studies to evaluate the safety, optimal dose range, and efficacy of stimulant therapies in this population.
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Affiliation(s)
- Megan E Barra
- Department of Pharmacy, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Aliyah Sarro-Schwartz
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ronald E Hirschberg
- Department of Physical Medicine and Rehabilitation, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicole Mazwi
- Department of Physical Medicine and Rehabilitation, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, 2348Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.,Athinoula A. Martinos Center for Biomedical Imaging, 2348Massachusetts General Hospital, Charlestown, MA, USA
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48
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Rubin DB, Danish HH, Ali AB, Li K, LaRose S, Monk AD, Cote DJ, Spendley L, Kim AH, Robertson MS, Torre M, Smith TR, Izzy S, Jacobson CA, Lee JW, Vaitkevicius H. Neurological toxicities associated with chimeric antigen receptor T-cell therapy. Brain 2019; 142:1334-1348. [DOI: 10.1093/brain/awz053] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/21/2018] [Accepted: 01/18/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Daniel B Rubin
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Husain H Danish
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Ali Basil Ali
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Karen Li
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah LaRose
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew D Monk
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David J Cote
- Department of Neurosurgery; Channing Division of Network Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Lauren Spendley
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Angela H Kim
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew S Robertson
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew Torre
- Department of Pathology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Timothy R Smith
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Caron A Jacobson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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49
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Das AS, Lee JW, Izzy S, Vaitkevicius H. Ultra-short burst suppression as a "reset switch" for refractory status epilepticus. Seizure 2018; 64:41-44. [PMID: 30553087 DOI: 10.1016/j.seizure.2018.11.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Revised: 11/27/2018] [Accepted: 11/29/2018] [Indexed: 11/18/2022] Open
Affiliation(s)
- Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, United States.
| | - Jong Woo Lee
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States.
| | - Saef Izzy
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States.
| | - Henrikas Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, United States.
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50
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Abstract
The neuroimmune system is involved in development, normal functioning, aging, and injury of the central nervous system. Microglia, first described a century ago, are the main neuroimmune cells and have three essential functions: a sentinel function involved in constant sensing of changes in their environment, a housekeeping function that promotes neuronal well-being and normal operation, and a defense function necessary for responding to such changes and providing neuroprotection. Microglia use a defined armamentarium of genes to perform these tasks. In response to specific stimuli, or with neuroinflammation, microglia also have the capacity to damage and kill neurons. Injury to neurons in Alzheimer's, Parkinson's, Huntington's, and prion diseases, as well as in amyotrophic lateral sclerosis, frontotemporal dementia, and chronic traumatic encephalopathy, results from disruption of the sentinel or housekeeping functions and dysregulation of the defense function and neuroinflammation. Pathways associated with such injury include several sensing and housekeeping pathways, such as the Trem2, Cx3cr1 and progranulin pathways, which act as immune checkpoints to keep the microglial inflammatory response under control, and the scavenger receptor pathways, which promote clearance of injurious stimuli. Peripheral interference from systemic inflammation or the gut microbiome can also alter progression of such injury. Initiation or exacerbation of neurodegeneration results from an imbalance between these microglial functions; correcting such imbalance may be a potential mode for therapy.
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Affiliation(s)
- Suzanne Hickman
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA
| | - Saef Izzy
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pritha Sen
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA
| | - Liza Morsett
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA
| | - Joseph El Khoury
- Center for Immunology & Inflammatory Diseases, Massachusetts General Hospital, and Harvard Medical School, Boston, MA, USA.
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