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Vespa P, Wolahan S, Buitrago-Blanco M, Real C, Ruiz-Tejeda J, McArthur DL, Chiang JN, Agoston D, Glenn TC. Exogenous lactate infusion (ELI) in traumatic brain injury: higher dose is better? Crit Care 2025; 29:153. [PMID: 40229764 PMCID: PMC11998250 DOI: 10.1186/s13054-025-05374-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2025] [Accepted: 03/15/2025] [Indexed: 04/16/2025] Open
Abstract
BACKGROUND/OBJECTIVE Traumatic brain injury (TBI) is a life-threatening critical neurological injury resulting in widespread metabolic dysfunction in need of novel metabolic therapy. Exogenous lactate appears to improve brain metabolism, but the dose of lactate required remains uncertain. However, the ideal dose of lactate remains unclear. We present a comparison of low vs high dose exogenous sodium lactate infusion in a small cohort and the previous existing literature. We propose a systematic protocol to better study the question of dose-effect n in a future larger study. METHODS We analyzed the metabolic and physiologic effects of various doses of exogenous sodium lactate infusion (ELI) in the existing published literature and our own, single center cohort of patients with coma from severe TBI. Low dose ELI targeting arterial lactate concentration of 2-3 mMol was compared with high dose ELI targeting 4-6 mM. Effects of ELI on brain metabolism and intracranial pressure (ICP) were reviewed. A precision high-dose protocol was piloted and results compared against the existing literature. RESULTS Across various studies, metabolic response to ELI was variable and not consistently beneficial. High-dose ELI targeting arterial concentration of 4-6 mM resulted in consistent metabolic improvement and in ICP reduction (p < 0.01). The precision high dose protocol reliably resulted in higher arterial concentration. CONCLUSIONS High dose ELI appears to have more consistent beneficial effects on brain metabolism and intracranial pressure. TRIAL REGISTRATION ClinicalTrials.gov ID NCT02776488. Date registered: 2016-05-17. Retrospectively Registered.
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Affiliation(s)
- Paul Vespa
- UCLA Department of Neurology, UCLA Department of Neurosurgery, UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Room 6236 A, Los Angeles, CA, 90095, USA.
| | - Stephanie Wolahan
- UCLA Department of Neurology, UCLA Department of Neurosurgery, UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Room 6236 A, Los Angeles, CA, 90095, USA
| | - Manuel Buitrago-Blanco
- UCLA Department of Neurology, UCLA Department of Neurosurgery, UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Room 6236 A, Los Angeles, CA, 90095, USA
| | - Courtney Real
- UCLA Department of Neurology, UCLA Department of Neurosurgery, UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Room 6236 A, Los Angeles, CA, 90095, USA
| | - Jesus Ruiz-Tejeda
- Department of Oncology, University of California, Irvine, Irvine, USA
| | - David L McArthur
- UCLA Department of Neurology, UCLA Department of Neurosurgery, UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Room 6236 A, Los Angeles, CA, 90095, USA
| | - Jeffrey N Chiang
- UCLA Department of Neurology, UCLA Department of Neurosurgery, UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Room 6236 A, Los Angeles, CA, 90095, USA
| | | | - Thomas C Glenn
- UCLA Department of Neurology, UCLA Department of Neurosurgery, UCLA Brain Injury Research Center, David Geffen School of Medicine at UCLA, 757 Westwood Blvd., Room 6236 A, Los Angeles, CA, 90095, USA
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Hwang IJ, Jeong TS, Kim WS, Kim JO, Jang MJ. Epidemiology and Outcomes of Severe Traumatic Brain Injury: Regional Trauma Center in Incheon, Korea, 2018-2022. Korean J Neurotrauma 2024; 20:17-26. [PMID: 38576499 PMCID: PMC10990697 DOI: 10.13004/kjnt.2024.20.e9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 02/26/2024] [Accepted: 03/06/2024] [Indexed: 04/06/2024] Open
Abstract
Objective This study aims to explore the epidemiology and outcomes of severe traumatic brain injury (TBI) in Incheon, focusing on regional characteristics using data from a local trauma center. Methods From January 2018 to December 2022, 559 patients with severe TBI were studied. We analyzed factors related to demography, prehospitalization, surgery, complications, and clinical outcomes, including intensive care unit stay, ventilator use, hospital stay, mortality, and Glasgow outcome scale (GOS) scores at discharge and after 6 months. Results In this study, most severe TBI patients were in the 60-79 age range, constituting 37.4% of cases. Most patients (74.1%) used public emergency medical services for transportation, and 75.3% arrived directly at the hospital, a significantly higher proportion compared to transferred patients. Timewise, 40.0% reached the hospital within an hour of injury. Complication rates stood at 16.1%, with pneumonia being the most common. The mortality rate was 44.0%, and at discharge, 81.2% of patients had unfavorable outcomes (GOS 1-3), reducing to 70.1% at 6 months. Conclusion As a pioneering study at Incheon's trauma center, this research provides insights into severe TBI outcomes, enhancing understanding by contrasting local and national data.
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Affiliation(s)
- Ik Jun Hwang
- Department of Neurosurgery, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Tae Seok Jeong
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Woo Seok Kim
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Jung Ook Kim
- Department of Traumatology, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| | - Myung Jin Jang
- Regional Trauma Center, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
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Jangra A, Gola P, Singh J, Gond P, Ghosh S, Rachamalla M, Dey A, Iqbal D, Kamal M, Sachdeva P, Jha SK, Ojha S, Kumar D, Jha NK, Chopra H, Tan SC. Emergence of taurine as a therapeutic agent for neurological disorders. Neural Regen Res 2024; 19:62-68. [PMID: 37488845 PMCID: PMC10479846 DOI: 10.4103/1673-5374.374139] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 03/01/2023] [Accepted: 03/28/2023] [Indexed: 07/26/2023] Open
Abstract
Taurine is a sulfur-containing, semi-essential amino acid that occurs naturally in the body. It alternates between inflammation and oxidative stress-mediated injury in various disease models. As part of its limiting functions, taurine also modulates endoplasmic reticulum stress, Ca2+ homeostasis, and neuronal activity at the molecular level. Taurine effectively protects against a number of neurological disorders, including stroke, epilepsy, cerebral ischemia, memory dysfunction, and spinal cord injury. Although various therapies are available, effective management of these disorders remains a global challenge. Approximately 30 million people are affected worldwide. The design of taurine formation could lead to potential drugs/supplements for the health maintenance and treatment of central nervous system disorders. The general neuroprotective effects of taurine and the various possible underlying mechanisms are discussed in this review. This article is a good resource for understanding the general effects of taurine on various diseases. Given the strong evidence for the neuropharmacological efficacy of taurine in various experimental paradigms, it is concluded that this molecule should be considered and further investigated as a potential candidate for neurotherapeutics, with emphasis on mechanism and clinical studies to determine efficacy.
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Affiliation(s)
- Ashok Jangra
- Department of Pharmaceutical Sciences, Central University of Haryana, Mahendergarh, Haryana, India
| | - Priyanka Gola
- Department of Pharmaceutical Sciences, Central University of Haryana, Mahendergarh, Haryana, India
| | - Jiten Singh
- Department of Pharmaceutical Sciences, Central University of Haryana, Mahendergarh, Haryana, India
| | - Pooja Gond
- Department of Pharmaceutical Sciences, Central University of Haryana, Mahendergarh, Haryana, India
| | - Swarnabha Ghosh
- Department of Pharmaceutical Sciences, Central University of Haryana, Mahendergarh, Haryana, India
| | - Mahesh Rachamalla
- Department of Biology, University of Saskatchewan, Saskatoon, SK, Canada
| | - Abhijit Dey
- Department of Life Sciences, Presidency University, Kolkata, West Bengal, India
| | - Danish Iqbal
- Department of Health Information Management, College of Applied Medical Sciences, Buraydah Private Colleges, Buraydah, Saudi Arabia
| | - Mehnaz Kamal
- Department of Pharmaceutical Chemistry, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al-Kharj, Saudi Arabia
| | | | - Saurabh Kumar Jha
- Department of Biotechnology, School of Engineering & Technology (SET), Sharda University, Greater Noida, Uttar Pradesh, India
| | - Shreesh Ojha
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Dinesh Kumar
- Department of Pharmaceutical Sciences, Central University of Haryana, Mahendergarh, Haryana, India
| | - Niraj Kumar Jha
- Department of Biotechnology, School of Engineering & Technology (SET), Sharda University, Greater Noida, Uttar Pradesh, India
- School of Bioengineering & Biosciences, Lovely Professional University, Phagwara, India
- Department of Biotechnology, School of Applied & Life Sciences (SALS), Uttaranchal University, Dehradun, India
| | - Hitesh Chopra
- Chitkara College of Pharmacy, Chitkara University, Punjab, India
| | - Shing Cheng Tan
- UKM Medical Molecular Biology Institute, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
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O'Brien NF, Chetcuti K, Fonseca Y, Vidal L, Raghavan P, Postels DG, Chimalizeni Y, Ray S, Seydel KB, Taylor TE. Cerebral Metabolic Crisis in Pediatric Cerebral Malaria. J Pediatr Intensive Care 2023; 12:278-288. [PMID: 37970136 PMCID: PMC10631841 DOI: 10.1055/s-0041-1732444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 06/12/2021] [Indexed: 10/20/2022] Open
Abstract
Cerebral metabolic energy crisis (CMEC), often defined as a cerebrospinal fluid (CSF) lactate: pyruvate ratio (LPR) >40, occurs in various diseases and is associated with poor neurologic outcomes. Cerebral malaria (CM) causes significant mortality and neurodisability in children worldwide. Multiple factors that could lead to CMEC are plausible in these patients, but its frequency has not been explored. Fifty-three children with CM were enrolled and underwent analysis of CSF lactate and pyruvate levels. All 53 patients met criteria for a CMEC (median CSF LPR of 72.9 [interquartile range [IQR]: 58.5-93.3]). Half of children met criteria for an ischemic CMEC (median LPR of 85 [IQR: 73-184]) and half met criteria for a nonischemic CMEC (median LPR of 60 [IQR: 54-79]. Children also underwent transcranial doppler ultrasound investigation. Cerebral blood flow velocities were more likely to meet diagnostic criteria for low flow (<2 standard deviation from normal) or vasospasm in children with an ischemic CMEC (73%) than in children with a nonischemic CMEC (20%, p = 0.04). Children with an ischemic CMEC had poorer outcomes (pediatric cerebral performance category of 3-6) than those with a nonischemic CMEC (46 vs. 22%, p = 0.03). CMEC was ubiquitous in this patient population and the processes underlying the two subtypes (ischemic and nonischemic) may represent targets for future adjunctive therapies.
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Affiliation(s)
- Nicole F. O'Brien
- Division of Critical Care Medicine, Department of Pediatrics, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, United States
| | - Karen Chetcuti
- Department of Radiology, College of Medicine, Chichiri, Blantyre, Malawi
| | - Yudy Fonseca
- Division of Critical Care Medicine, Department of Pediatrics, University of Maryland Medical Center, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Lorenna Vidal
- Division of Neuroradiology, Department of Radiology Children's Hospital of Philadelphia, Clinical Instructor at Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Prashant Raghavan
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Douglas G. Postels
- Department of Neurology, George Washington University/Children's National Medical Center, Washington, District of Columbia, United States
| | - Yamikani Chimalizeni
- Department of Pediatrics and Child Health, University of Malawi, Malawi College of Medicine, Chichiri, Blantyre, Malawi
| | - Stephen Ray
- Department of Paediatric, Malawi Liverpool Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Karl B. Seydel
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
- Blantyre Malaria Project, Blantyre, Malawi
| | - Terrie E. Taylor
- Department of Osteopathic Medical Specialties, College of Osteopathic Medicine, Michigan State University, East Lansing, Michigan, United States
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Sakas R, Dan K, Edelman D, Abu-Ata S, Ben-Menashe A, Awad-Igbaria Y, Francois-Soustiel J, Palzur E. Hyperbaric Oxygen Therapy Alleviates Memory and Motor Impairments Following Traumatic Brain Injury via the Modulation of Mitochondrial-Dysfunction-Induced Neuronal Apoptosis in Rats. Antioxidants (Basel) 2023; 12:2034. [PMID: 38136154 PMCID: PMC10740762 DOI: 10.3390/antiox12122034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/07/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults, characterized by primary and secondary injury. Primary injury is the immediate mechanical damage, while secondary injury results from delayed neuronal death, often linked to mitochondrial damage accumulation. Hyperbaric oxygen therapy (HBOT) has been proposed as a potential treatment for modulating secondary post-traumatic neuronal death. However, the specific molecular mechanism by which HBOT modulates secondary brain damage through mitochondrial protection remains unclear. Spatial learning, reference memory, and motor performance were measured in rats before and after Controlled Cortical Impact (CCI) injury. The HBOT (2.5 ATA) was performed 4 h following the CCI and twice daily (12 h intervals) for four consecutive days. Mitochondrial functions were assessed via high-resolution respirometry on day 5 following CCI. Moreover, IHC was performed at the end of the experiment to evaluate cortical apoptosis, neuronal survival, and glial activation. The current result indicates that HBOT exhibits a multi-level neuroprotective effect. Thus, we found that HBOT prevents cortical neuronal loss, reduces the apoptosis marker (cleaved-Caspase3), and modulates glial cell proliferation. Furthermore, HBO treatment prevents the reduction in mitochondrial respiration, including non-phosphorylation state, oxidative phosphorylation, and electron transfer capacity. Additionally, a superior motor and spatial learning performance level was observed in the CCI group treated with HBO compared to the CCI group. In conclusion, our findings demonstrate that HBOT during the critical period following the TBI improves cognitive and motor damage via regulating glial proliferation apoptosis and protecting mitochondrial function, consequently preventing cortex neuronal loss.
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Affiliation(s)
- Reem Sakas
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Katya Dan
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Doron Edelman
- Neurosurgery Department, Tel-Aviv Sourasky Medical Center, Tel-Aviv 6423906, Israel;
| | - Saher Abu-Ata
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Aviv Ben-Menashe
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Yaseen Awad-Igbaria
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Jean Francois-Soustiel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Neurosurgery Department, Galilee Medical Center, Nahariya 221001, Israel
| | - Eilam Palzur
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
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Gerlach R, Kluwe W. [Prehospital care of pediatric traumatic brain injury]. Med Klin Intensivmed Notfmed 2023; 118:626-637. [PMID: 37450022 DOI: 10.1007/s00063-023-01046-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Traumatic brain injury (TBI) in children and adolescents is associated with significant morbidity and, in severe TBI, mortality. The aim of this article is to provide an overview of the spectrum of TBI, its pathophysiology, and current treatment recommendations for prehospital management of children and adolescents with TBI. MATERIALS AND METHODS The current literature was reviewed for studies on the management of TBI in children and adolescents. RESULTS In recent years, a large number of scientific studies have been published that have resulted in evidence-based guidelines for primary care of children with TBI. The primary aim is to minimize secondary brain damage following TBI, for which immediate assessment of the severity of TBI at the scene based on clinical findings and the accident mechanism and initiation of specific treatment measures to prevent hypoxia, hypotension, and hypothermia are critical. Not only prehospital management, but also the rapid transfer of children with severe TBI to centers with high neurosurgical, pediatric surgical, and pediatric intensive care expertise is of particular importance to improve survival and neurological outcome after severe TBI. CONCLUSION Structured prehospital management may help reduce secondary brain injury after TBI and lead to improved clinical outcomes.
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Affiliation(s)
- Rüdiger Gerlach
- Klinik für Neurochirurgie, Helios Klinikum Erfurt, Nordhäuser Str. 74, 99089, Erfurt, Deutschland.
| | - Wolfram Kluwe
- Klinik für Kinderchirurgie und Kinderurologie, Helios Klinikum Erfurt, Erfurt, Deutschland
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Fedoruk RP, Lee CH, Banoei MM, Winston BW. Metabolomics in severe traumatic brain injury: a scoping review. BMC Neurosci 2023; 24:54. [PMID: 37845610 PMCID: PMC10577974 DOI: 10.1186/s12868-023-00824-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 09/29/2023] [Indexed: 10/18/2023] Open
Abstract
BACKGROUND Diagnosis and prognostication of severe traumatic brain injury (sTBI) continue to be problematic despite years of research efforts. There are currently no clinically reliable biomarkers, though advances in protein biomarkers are being made. Utilizing Omics technology, particularly metabolomics, may provide new diagnostic biomarkers for sTBI. Several published studies have attempted to determine the specific metabolites and metabolic pathways involved; these studies will be reviewed. AIMS This scoping review aims to summarize the current literature concerning metabolomics in sTBI, review the comprehensive data, and identify commonalities, if any, to define metabolites with potential clinical use. In addition, we will examine related metabolic pathways through pathway analysis. METHODS Scoping review methodology was used to examine the current literature published in Embase, Scopus, PubMed, and Medline. An initial 1090 publications were identified and vetted with specific inclusion criteria. Of these, 20 publications were selected for further examination and summary. Metabolic data was classified using the Human Metabolome Database (HMDB) and arranged to determine the 'recurrent' metabolites and classes found in sTBI. To help understand potential mechanisms of injury, pathway analysis was performed using these metabolites and the Kyoto Encyclopedia of Genes and Genomes (KEGG) Pathway Database. RESULTS Several metabolites related to sTBI and their effects on biological pathways were identified in this review. Across the literature, proline, citrulline, lactate, alanine, valine, leucine, and serine all decreased in adults post sTBI, whereas both octanoic and decanoic acid increased. Hydroxy acids and organooxygen compounds generally increased following sTBI, while most carboxylic acids decreased. Pathway analysis showed significantly affected glycine and serine metabolism, glycolysis, branched-chain amino acid (BCAA) metabolism, and other amino acid metabolisms. Interestingly, no tricarboxylic acid cycle metabolites were affected. CONCLUSION Aside from a select few metabolites, classification of a metabolic profile proved difficult due to significant ambiguity between study design, sample size, type of sample, metabolomic detection techniques, and other confounding variables found in sTBI literature. Given the trends found in some studies, further metabolomics investigation of sTBI may be useful to identify clinically relevant metabolites.
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Affiliation(s)
- Riley Page Fedoruk
- Department of Critical Care, Cumming School of Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
| | - Chel Hee Lee
- Department of Critical Care, Cumming School of Medicine, Alberta Health Services and University of Calgary, Calgary, Canada
- Department of Mathematics and Statistics, Faculty of Science, University of Calgary, Calgary, Canada
| | | | - Brent W Winston
- Department of Critical Care, Cumming School of Medicine, Alberta Health Services and University of Calgary, Calgary, Canada.
- Departments of Medicine and Biochemistry and Molecular Biology, Cumming School of Medicine, University of Calgary, Calgary, Canada.
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Li Z, Feng Y, Wang P, Han S, Zhang K, Zhang C, Lu S, Lv C, Zhu F, Bie L. Evaluation of the prognosis of acute subdural hematoma according to the density differences between gray and white matter. Front Neurol 2023; 13:1024018. [PMID: 36686517 PMCID: PMC9853902 DOI: 10.3389/fneur.2022.1024018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Accepted: 11/21/2022] [Indexed: 01/07/2023] Open
Abstract
Objective Acute subdural hematoma (ASDH) is a common neurological emergency, and its appearance on head-computed tomographic (CT) imaging helps guide clinical treatment. To provide a basis for clinical decision-making, we analyzed that the density difference between the gray and white matter of the CT image is associated with the prognosis of patients with ASDH. Methods We analyzed the data of 194 patients who had ASDH as a result of closed traumatic brain injury (TBI) between 2018 and 2021. The patients were subdivided into surgical and non-surgical groups, and the non-surgical group was further subdivided into "diffused [hematoma]" and "non-diffused" groups. The control group's CT scans were normal. The 3D Slicer software was used to quantitatively analyze the density of gray and white matter depicted in the CT images. Results Imaging evaluation showed that the median difference in density between the gray and white matter on the injured side was 4.12 HU (IQR, 3.91-4.22 HU; p < 0.001) and on the non-injured side was 4.07 HU (IQR, 3.90-4.19 HU; p < 0.001), and the hematoma needs to be surgically removed. The median density difference value of the gray and white matter on the injured side was 3.74 HU (IQR, 3.53-4.01 HU; p < 0.001) and on the non-injured side was 3.71 HU (IQR, 3.69-3.73 HU; p < 0.001), and the hematoma could diffuse in a short time. Conclusion Quantitative analysis of the density differences in the gray and white matter of the CT images can be used to evaluate the clinical prognosis of patients with ASDH.
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Affiliation(s)
- Zean Li
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Yan Feng
- Department of Radiology of the First Clinical Hospital, Jilin University, Changchun, China
| | - Pengju Wang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shuai Han
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Kang Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Chunyun Zhang
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Shouyong Lu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Chuanxiang Lv
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Fulei Zhu
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China
| | - Li Bie
- Department of Neurosurgery of the First Clinical Hospital, Jilin University, Changchun, China,*Correspondence: Li Bie
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Jain R, The CS, Murphy MM, Pandit AS. Surgical significance of prolonged fixed and dilated pupils in a case of non-traumatic, spontaneously regressing, acute subdural haemorrhage. BMJ Case Rep 2022; 15:e247388. [PMID: 35473704 PMCID: PMC9045004 DOI: 10.1136/bcr-2021-247388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2022] [Indexed: 11/04/2022] Open
Abstract
Bilaterally fixed and dilated pupils (BFDP) in traumatic acute subdural haematoma (ASDH) patients represent an ominous sign that portends irreversible brainstem injury and death. Whether patients with spontaneous ASDH and BFDP follow similar outcomes is unknown. We present a mid-60s man, found unconscious, with a Glasgow Coma Scale (GCS) of 4 following 8 days of headaches. Emergency CT imaging demonstrated a large right ASDH and the patient exhibited BFDP for >3 hours despite sedation and mannitol. Neurological improvement and spontaneously reduced SDH thickness were observed 10 hours postadmission, and he was later transferred for craniotomy and ASDH evacuation. His long-term outcomes were good: achieving independence in his activities of daily living and a GCS of 15. To the best of our knowledge, this is the first reported patient with a spontaneous, regressing ASDH and prolonged BFDP who clinically improved. This case raises important questions regarding factors used to determine prognosis and surgical viability for ASDH.
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Affiliation(s)
- Raunak Jain
- Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Crystallynn Skye The
- Medical School, Faculty of Medical Sciences, University College London, London, UK
| | - Mary M Murphy
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
| | - Anand S Pandit
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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Palzur E, Edelman D, Sakas R, Soustiel JF. Etifoxine Restores Mitochondrial Oxidative Phosphorylation and Improves Cognitive Recovery Following Traumatic Brain Injury. Int J Mol Sci 2021; 22:12881. [PMID: 34884686 PMCID: PMC8657969 DOI: 10.3390/ijms222312881] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 12/05/2022] Open
Abstract
The opening of the mitochondrial permeability transition pore (mPTP) has emerged as a pivotal event following traumatic brain injury (TBI). Evidence showing the impact of the translocator protein (TSPO) over mPTP activity has prompted several studies exploring the effect of TSPO ligands, including etifoxine, on the outcome of traumatic brain injury (TBI). Mitochondrial respiration was assessed by respirometry in isolated rat brain mitochondria (RBM) by measurements of oxidative phosphorylation capacity (OXPHOS). The addition of calcium to RBM was used to induce mitochondrial injury and resulted in significant OXPHOS reduction that could be reversed by preincubation of RBM with etifoxine. Sensorimotor and cognitive functions were assessed following controlled cortical impact and compared in vehicle and etifoxine-treated animals. There was no difference between the vehicle and etifoxine groups for sensorimotor functions as assessed by rotarod. In contrast, etifoxine resulted in a significant improvement of cognitive functions expressed by faster recovery in Morris water maze testing. The present findings show a significant neuroprotective effect of etifoxine in TBI through restoration of oxidative phosphorylation capacity associated with improved behavioral and cognitive outcomes. Since etifoxine is a registered drug used in common clinical practice, implementation in a phase II study may represent a reasonable step forward.
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Affiliation(s)
- Eilam Palzur
- Eliachar Research Laboratory, Galilee Medical Center, Nahariya 2210001, Israel; (E.P.); (R.S.)
| | - Doron Edelman
- Galilee Medical Center, Department of Neurosurgery, Nahariya 2210001, Israel;
| | - Reem Sakas
- Eliachar Research Laboratory, Galilee Medical Center, Nahariya 2210001, Israel; (E.P.); (R.S.)
| | - Jean Francois Soustiel
- Eliachar Research Laboratory, Galilee Medical Center, Nahariya 2210001, Israel; (E.P.); (R.S.)
- Galilee Medical Center, Department of Neurosurgery, Nahariya 2210001, Israel;
- Azrieli Faculty of Medicine, University of Bar Ilan, Zafed 1311502, Israel
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Bhatt R, Khanna P. Role of Ultrasound in Neurocritical Care. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2021. [DOI: 10.1055/s-0040-1712069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractBedside point of care ultrasound has acquired an extremely significant role in diagnosis and management of neurocritical care, just as it has in other specialties. Easy availability and increasing expertise have allowed the intensivists to use it in a wide array of situations, such as confirming clinical findings as well as for interventional and prognostic purposes. At present, the clinical applications of ultrasonography (USG) in a neurosurgical patient include estimation of elevated intracranial pressure (ICP), assessment of cerebral blood flow (CBF) and velocities, diagnosis of intracranial mass lesion and midline shifts, and examination of pupils, apart from the systemic applications. Transcranial sonography has also found use in the diagnosis of the cerebral circulatory arrest. An increasing number of clinicians are now relying on the use of ultrasound in the neurointensive care unit for neurological as well as non-neurological indications. These uses include the diagnosis of shock, respiratory failure, deep vein thrombosis and performing bedside procedures.
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Affiliation(s)
- Rashmi Bhatt
- International Training Fellow, Aberdeen Royal Infirmary, Aberdeen, Scotland
| | - Puneet Khanna
- Department of Anaesthesiology, Pain Medicine & Critical Care, All India Institute of Medical Sciences, New Delhi, India
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Sugar as a therapeutic target for the cognitive restoration following traumatic brain injury. Curr Opin Neurol 2019; 32:815-821. [PMID: 31609736 DOI: 10.1097/wco.0000000000000752] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW This review aims to discuss examples of changes in glucose (sugar) metabolism after traumatic brain injury (TBI). It will attempt to provide an understanding of what changes in glucose metabolism mean for the injured brain. It will further identify potential therapeutic target(s) emanating from our growing understanding of glucose pathways and their roles in TBI. RECENT FINDINGS Although a significant fraction of glucose is utilized for the energy production in the brain, a small fraction is utilized in other, often ignored pathways. Recent studies have unraveled unexpected biological effects of glucose through these pathways, including redox regulation, genetic and epigenetic regulation, glycation of proteins, nucleotide synthesis and amino acid synthesis. SUMMARY A number of regulatory players in minor glucose metabolic pathways, such as folate and chondroitin sulfate proteoglycans, have recently been identified as potential targets to restore cognitive functions. Targeting of these players should be combined with the supplementation of alternative energy substrates to achieve the maximal cognitive restoration after TBI. This multimodal therapeutic strategy deserves testing in various models of TBI. VIDEO ABSTRACT Supplemental digital video content 1: Video that demonstrates an effective therapeutic strategy for the cognitive restoration after TBI. http://links.lww.com/CONR/A46.
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Eun J, Huh J, Yang SY, Huh HY, Ahn JK, Cho KW, Kim YW, Kim SL, Kim JT, Yoo DS, Park HK, Ji C. Determining the Lower Limit of Cerebral Perfusion Pressure in Patients Undergoing Decompressive Craniectomy Following Traumatic Brain Injury. World Neurosurg 2017; 111:e32-e39. [PMID: 29203313 DOI: 10.1016/j.wneu.2017.11.146] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 11/23/2017] [Accepted: 11/25/2017] [Indexed: 11/13/2022]
Abstract
BACKGROUND In patients with severe traumatic brain injury (TBI), maintaining systolic blood pressure >90 mm Hg, intracranial pressure (ICP) <20 mm Hg and cerebral perfusion pressure (CPP) >60-70 mm Hg is recommended to improve clinical outcomes. A recommended CPP value for patients treated with decompressive craniectomy (DC) has not been clearly studied. We aimed to determine whether the targeted CPP can be lowered in patients treated with DC. METHODS This retrospective analysis included 191 patients who underwent DC for TBI. All patients were monitored for ICP and blood pressure during and after DC. CPP was calculated every 2 hours after DC. Patient outcomes were evaluated 6 months after initial treatment. RESULTS Mean patient age was 50.8 years (median 52 years), and 79.1% of patients were male. Initial Glasgow Coma Scale score was 6.2 (median 6). Comparing clinical outcome based on postoperative ICP >25 mm Hg and <25 mm Hg, Extended Glasgow Outcome Scale score was 1.4 (>25 mm Hg) and 4.9 (<25 mm Hg) (P = 0.000). In patients maintained at ICP <25 mm Hg, mortality was increased significantly with CPP between 35 mmHg and 30 mm Hg (χ2, P = 0.029 vs. P = 0.062). CONCLUSIONS Patients with TBI who underwent DC with postoperative ICP maintained <25 mm Hg and CPP >35 mm Hg may have similar mortality as patients with CPP >60-70 mm Hg who did not undergo DC. For patients with TBI who undergo DC, targeted CPP might be lowered to 35 mm Hg if ICP is maintained <25 mm Hg.
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Affiliation(s)
- Jin Eun
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Joon Huh
- Department of Neurosurgery, Myungji St. Mary's Hospital, Seoul, Republic of Korea
| | - Seo-Yeon Yang
- Department of Neurosurgery, Uijongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea
| | - Han-Yong Huh
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Jae-Kun Ahn
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Kwang-Wook Cho
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea
| | - Young-Woo Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea
| | - Sung-Lim Kim
- Department of Neurosurgery, Bucheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea
| | - Jong-Tae Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Incheon, Republic of Korea
| | - Do-Sung Yoo
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea; Department of Neurosurgery, Uijongbu St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Gyeonggi-Do, Republic of Korea.
| | - Hae-Kwan Park
- Department of Neurosurgery, Yeouido St. Mary's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
| | - Cheol Ji
- Department of Neurosurgery, St. Paul's Hospital, The Catholic University of Korea, College of Medicine, Seoul, Republic of Korea
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Decompressive craniectomy in the management of intracranial hypertension after traumatic brain injury: a systematic review and meta-analysis. Sci Rep 2017; 7:8800. [PMID: 28821777 PMCID: PMC5562822 DOI: 10.1038/s41598-017-08959-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 07/17/2017] [Indexed: 11/24/2022] Open
Abstract
We aim to perform a systematic review and meta-analysis to examine the prognostic value of decompressive craniectomy (DC) in patients with traumatic intracranial hypertension. PubMed, EMBASE, Cochrane Controlled Trials Register, Web of Science, http://clinicaltrials.gov/ were searched for eligible studies. Ten studies were included in the systematic review, with four randomized controlled trials involved in the meta-analysis, where compared with medical therapies, DC could significantly reduce mortality rate [risk ratio (RR), 0.59; 95% confidence interval (CI), 0.47–0.74, P < 0.001], lower intracranial pressure (ICP) [mean difference (MD), −2.12 mmHg; 95% CI, −2.81 to −1.43, P < 0.001], decrease the length of ICU stay (MD, −4.63 days; 95% CI, −6.62 to −2.65, P < 0.001) and hospital stay (MD, −14.39 days; 95% CI, −26.00 to −2.78, P = 0.02), but increase complications rate (RR, 1.94; 95% CI, 1.31–2.87, P < 0.001). No significant difference was detected for Glasgow Outcome Scale at six months (RR, 0.85; 95% CI, 0.61–1.18, P = 0.33), while in subgroup analysis, early DC would possibly result in improved prognosis (P = 0.04). Results from observational studies supported pooled results except prolonged length of ICU and hospital stay. Conclusively, DC seemed to effectively lower ICP, reduce mortality rate but increase complications rate, while its benefit on functional outcomes was not statistically significant.
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Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension. Front Neurol 2017; 8:250. [PMID: 28769857 PMCID: PMC5511895 DOI: 10.3389/fneur.2017.00250] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/19/2017] [Indexed: 12/30/2022] Open
Abstract
During traumatic brain injury, intracranial hypertension (ICH) can become a life-threatening condition if it is not managed quickly and adequately. Physicians use therapeutic hyperventilation to reduce elevated intracranial pressure (ICP) by manipulating autoregulatory functions connected to cerebrovascular CO2 reactivity. Inducing hypocapnia via hyperventilation reduces the partial pressure of arterial carbon dioxide (PaCO2), which incites vasoconstriction in the cerebral resistance arterioles. This constriction decrease cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient’s ICP. The effects of therapeutic hyperventilation (HV) are transient, but the risks accompanying these changes in cerebral and systemic physiology must be carefully considered before the treatment can be deemed advisable. The most prominent criticism of this approach is the cited possibility of developing cerebral ischemia and tissue hypoxia. While it is true that certain measures, such as cerebral oxygenation monitoring, are needed to mitigate these dangerous conditions, using available evidence of potential poor outcomes associated with HV as justification to dismiss the implementation of therapeutic HV is debatable and remains a controversial subject among physicians. This review highlights various issues surrounding the use of HV as a means of controlling posttraumatic ICH, including indications for treatment, potential risks, and benefits, and a discussion of what techniques can be implemented to avoid adverse complications.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina.,Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina
| | - Ali Seifi
- University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - David Garza
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
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Vlodavsky E, Palzur E, Shehadeh M, Soustiel JF. Post-traumatic cytotoxic edema is directly related to mitochondrial function. J Cereb Blood Flow Metab 2017; 37:166-177. [PMID: 26672111 PMCID: PMC5363733 DOI: 10.1177/0271678x15621068] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/26/2015] [Accepted: 11/11/2015] [Indexed: 01/15/2023]
Abstract
Cerebral edema represents a major threat following traumatic brain injury. However, therapeutic measures for control of intracranial pressure alone have failed to restore cerebral metabolism and improve neurological outcome. Since mitochondrial damage results in ATP depletion and deactivation of membrane ionic pumps, we hypothesized that modulation of ATP bioavailability may directly affect cytotoxic edema. Intracranial pressure measurements were performed in Sprague-Dawley rats treated by intraperitoneal injection of dimethylsulfoxide (vehicle), cyclosporine A (CsA), or Oligomycin B (OligB) following cortical contusion and further correlated with water content, mitochondrial damage, and electron microscopic assessment of neuronal and axonal edema. As hypothesized, ultra-structural figures of edema closely correlated with intracranial pressure elevation, increased water content and mitochondrial membrane permeabilization expressed by loss of transmembrane mitochondrial potential. Further, mitochondrial damage evidenced ultra-structurally by figures of swollen mitochondria with severely distorted cristae correlated with both cytotoxic edema and mitochondrial dysfunction. Importantly, cerebral edema and mitochondrial impairment were significantly worsened by treatment with OligB, whereas a noticeable improvement could be observed in animals that received injections of CsA. Since OligB and CsA are responsible for symmetrical and opposite effects on oxidative metabolism, these findings support the hypothesis of a causative relationship between edema and mitochondrial function.
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Affiliation(s)
- Eugene Vlodavsky
- Institute of Pathology, Rambam Medical Center, Haifa, Israel.,The Ruth & Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Eilam Palzur
- Eliachar Research Laboratory, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel
| | - Mona Shehadeh
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Jean F Soustiel
- Eliachar Research Laboratory, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel .,Department of Neurosurgery, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel
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18
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Abstract
Elevated intracranial pressure (ICP) is a primary cause of morbidity and mortality for many neurologic disorders. The relationship between ICP and brain volume is influenced by autoregulatory processes that can become dysfunctional. As a result, neurologic damage can occur by systemic and intracranial insults such as ischemia and excitatory amino acids. Therefore, survival is dependent on optimizing ICP and cerebral perfusion pressure. Treatment of intracranial hypertension requires intensive monitoring and aggressive therapy. Intracranial pressure monitoring techniques such as intraventricular catheters are useful for determining ICP elevations before changes in vital signs and neurologic status. Therapeutic modalities, generally aimed at reducing cerebral blood volume, brain tissue, and cerebrospinal fluid (CSF) volume, include nonpharmacologic (CSF removal, controlled hyperventilation, and elevating the patient’s head) and pharmacologic management. Mannitol and sedation are first-line agents used to lower ICP. Barbiturate coma may be beneficial in patients with elevated ICP refractory to conventional treatment. The use of prophylactic antiseizure therapy and optimal nutrition prevents significant complication. Currently, investigations are directed at discovering useful neuroprotective agents that prevent secondary neurologic injury.
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Affiliation(s)
- Beth A. Vanderheyden
- Department of Pharmacy Services, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD 21201,
| | - Brian D. Buck
- Department of Pharmacy Services, University of Maryland Medical Center, 22 S. Greene Street, Baltimore, MD 21201,
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Intracranial Pressure Monitoring in Severe Traumatic Brain Injury – Results of a Canadian Survey. Can J Neurol Sci 2016. [DOI: 10.1017/s0317167100052252] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACT:Objective:The purpose of this study was to obtain information from Canadian neurosurgeons regarding their opinions on, and utilization of, intracranial pressure (ICP) monitoring for severe traumatic brain injury (TBI).Methods:A brief survey was sent to practicing Canadian neurosurgeons questioning them about their utilization of, and confidence in, intracranial pressure monitoring in the management of patients with severe TBI.Results:One hundred and ninety-six surveys were mailed. There were 103 responses for a response rate of 52.6%. The vast majority of responding neurosurgeons (98.1%) utilized ICP monitoring in the management of patients with severe TBI, with most (63.4%) using it in more than 75% of their patients, 14.9% using it in 50-75% of patients, 14.9% in 25-50% of patients, and 6.9% using it in less than 25% of patients. The level of confidence that routine monitoring improves outcome from severe TBI ranged from 23.3% having a low level of confidence, 56.3% having an intermediate level of confidence, to 20.4% having a high level of confidence. Most respondents (78.6%) felt that some form of prospective trial evaluating the role of ICP monitoring in improving outcome from severe TBI was warranted; 17.4% felt such a trial was not warranted and 3.9% were uncertain.Conclusions:While ICP monitoring has gained almost universal acceptance among responding Canadian neurosurgeons, their level of confidence that routine monitoring improves outcome from severe TBI was quite variable, with only 20.4% of respondents having a high level of confidence. Over 75% of respondents felt that some form of prospective trial evaluating the utility of ICP monitoring is warranted. This information is being used in consideration of a prospective trial addressing this issue.
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D'Andrea A, Conte M, Cavallaro M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Carbone A, Natale F, Santoro G, Caso P, Russo MG, Bossone E, Calabrò R. Transcranial Doppler ultrasonography: From methodology to major clinical applications. World J Cardiol 2016; 8:383-400. [PMID: 27468332 PMCID: PMC4958690 DOI: 10.4330/wjc.v8.i7.383] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Revised: 04/29/2016] [Accepted: 05/17/2016] [Indexed: 02/06/2023] Open
Abstract
Non-invasive Doppler ultrasonographic study of cerebral arteries [transcranial Doppler (TCD)] has been extensively applied on both outpatient and inpatient settings. It is performed placing a low-frequency (≤ 2 MHz) transducer on the scalp of the patient over specific acoustic windows, in order to visualize the intracranial arterial vessels and to evaluate the cerebral blood flow velocity and its alteration in many different conditions. Nowadays the most widespread indication for TCD in outpatient setting is the research of right to left shunting, responsable of so called "paradoxical embolism", most often due to patency of foramen ovale which is responsable of the majority of cryptogenic strokes occuring in patients younger than 55 years old. TCD also allows to classify the grade of severity of such shunts using the so called "microembolic signal grading score". In addition TCD has found many useful applications in neurocritical care practice. It is useful on both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoidal haemorrhage (caused by aneurysm rupture or traumatic injury), traumatic brain injury, brain stem death. It is used also to evaluate cerebral hemodynamic changes after stroke. It also allows to investigate cerebral pressure autoregulation and for the clinical evaluation of cerebral autoregulatory reserve.
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Affiliation(s)
- Antonello D'Andrea
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Marianna Conte
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Massimo Cavallaro
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Raffaella Scarafile
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Lucia Riegler
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Rosangela Cocchia
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Enrica Pezzullo
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Andreina Carbone
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Francesco Natale
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Giuseppe Santoro
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Pio Caso
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Maria Giovanna Russo
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Eduardo Bossone
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
| | - Raffaele Calabrò
- Antonello D'Andrea, Marianna Conte, Massimo Cavallaro, Raffaella Scarafile, Lucia Riegler, Rosangela Cocchia, Enrica Pezzullo, Andreina Carbone, Francesco Natale, Giuseppe Santoro, Pio Caso, Maria Giovanna Russo, Raffaele Calabrò, Integrated Diagnostic Cardiology, Second University of Naples, AORN "dei Colli", Monaldi Hospital, 80121 Naples, Italy
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Honda M, Ichibayashi R, Yokomuro H, Yoshihara K, Masuda H, Haga D, Seiki Y, Kudoh C, Kishi T. Early Cerebral Circulation Disturbance in Patients Suffering from Severe Traumatic Brain Injury (TBI): A Xenon CT and Perfusion CT Study. Neurol Med Chir (Tokyo) 2016; 56:501-9. [PMID: 27356957 PMCID: PMC4987450 DOI: 10.2176/nmc.oa.2015-0341] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Traumatic brain injury (TBI) is widely known to cause dynamic changes in cerebral blood flow (CBF). Ischemia is a common and deleterious secondary injury following TBI. Detecting early ischemia in TBI patients is important to prevent further advancement and deterioration of the brain tissue. The purpose of this study was to clarify the cerebral circulatory disturbance during the early phase and whether it can be used to predict patient outcome. A total of 90 patients with TBI underwent a xenon-computed tomography (Xe-CT) and subsequently perfusion CT to evaluate the cerebral circulation on days 1–3. We measured CBF using Xe-CT and mean transit time (MTT: the width between two inflection points [maximum upward slope and maximum downward slope from inflow to outflow of the contrast agent]) using perfusion CT and calculated the cerebral blood volume (CBV) using the AZ-7000W98 computer system. The relationships of the hemodynamic parameters CBF, MTT, and CBV to the Glasgow Coma Scale (GCS) score and the Glasgow Outcome Scale (GOS) score were examined. There were no significant differences in CBF, MTT, and CBV among GCS3–4, GCS5–6, and GCS7–8 groups. The patients with a favorable outcome (GR and MD) had significantly higher CBF and lower MTT than those with an unfavorable one (SD, VS, or D). The discriminant analysis of these parameters could predict patient outcome with a probability of 70.6%. During the early phase, CBF reduction and MTT prolongation might influence the clinical outcome of TBI. These parameters are helpful for evaluating the severity of cerebral circulatory disturbance and predicting the outcome of TBI patients.
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Affiliation(s)
- Mitsuru Honda
- Department of Critical Care Center, Toho University Medical Center Omori Hospital
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Wang Q, Fan W, Cai Y, Wu Q, Mo L, Huang Z, Huang H. Protective effects of taurine in traumatic brain injury via mitochondria and cerebral blood flow. Amino Acids 2016; 48:2169-77. [PMID: 27156064 DOI: 10.1007/s00726-016-2244-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 04/25/2016] [Indexed: 12/12/2022]
Abstract
In mammalian tissues, taurine is an important natural component and the most abundant free amino acid in the heart, retina, skeletal muscle, brain, and leukocytes. This study is to examine the taurine's protective effects on neuronal ultrastructure, the function of the mitochondrial respiratory chain complex, and on cerebral blood flow (CBF). The model of traumatic brain injury (TBI) was made for SD rats by a fluid percussion device, with taurine (200 mg/kg) administered by tail intravenous injection once daily for 7 days after TBI. It was found that CBF was improved for both left and right brain at 30 min and 7 days post-injury by taurine. Reaction time was prolonged relative to the TBI-only group. Neuronal damage was prevented by 7 days taurine. Mitochondrial electron transport chain complexes I and II showed greater activity with the taurine group. The improvement by taurine of CBF may alleviate edema and elevation in intracranial pressure. Importantly taurine improved the hypercoagulable state.
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Affiliation(s)
- Qin Wang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China.,Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurological Institute, Tianjin Huanhu Hospital, No. 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Weijia Fan
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurological Institute, Tianjin Huanhu Hospital, No. 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Ying Cai
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurological Institute, Tianjin Huanhu Hospital, No. 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Qiaoli Wu
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurological Institute, Tianjin Huanhu Hospital, No. 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Lidong Mo
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurological Institute, Tianjin Huanhu Hospital, No. 6 Jizhao Road, Jinnan District, Tianjin, 300350, China
| | - Zhenwu Huang
- National Institute for Nutrition and Health, Chinese Center for Disease Control and Prevention, 27 Nanwei Road, Xicheng District, Beijing, 100050, China
| | - Huiling Huang
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurological Institute, Tianjin Huanhu Hospital, No. 6 Jizhao Road, Jinnan District, Tianjin, 300350, China.
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23
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D'Andrea A, Conte M, Scarafile R, Riegler L, Cocchia R, Pezzullo E, Cavallaro M, Carbone A, Natale F, Russo MG, Gregorio G, Calabrò R. Transcranial Doppler Ultrasound: Physical Principles and Principal Applications in Neurocritical Care Unit. J Cardiovasc Echogr 2016; 26:28-41. [PMID: 28465958 PMCID: PMC5224659 DOI: 10.4103/2211-4122.183746] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Transcranial Doppler (TCD) ultrasonography is a noninvasive ultrasound study, which has been extensively applied on both outpatient and inpatient settings. It involves the use of a low-frequency (≤2 MHz) transducer, placed on the scalp, to insonate the basal cerebral arteries through relatively thin bone windows and to measure the cerebral blood flow velocity and its alteration in many different conditions. In neurointensive care setting, TCD is useful for both adults and children for day-to-day bedside assessment of critical conditions including vasospasm in subarachnoid hemorrhage, traumatic brain injury, acute ischemic stroke, and brain stem death. It also allows to investigate the cerebrovascular autoregulation in setting of carotid disease and syncope. In this review, we will describe physical principles underlying TCD, flow indices most frequently used in clinical practice and critical care applications in Neurocritical Unit care.
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Affiliation(s)
- Antonello D'Andrea
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Marianna Conte
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Raffaella Scarafile
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Lucia Riegler
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Rosangela Cocchia
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Enrica Pezzullo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Massimo Cavallaro
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Andreina Carbone
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Francesco Natale
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Maria Giovanna Russo
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
| | - Giovanni Gregorio
- Department of Cardiology, San Luca Hospital, Vallo della Lucania, Salerno, Italy
| | - Raffaele Calabrò
- Department of Cardiology, Integrated Diagnostic Cardiology, Second University of Neaples, Monaldi Hospital, Neaples, Italy
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24
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Li C, Wu PM, Wu Z, Limnuson K, Mehan N, Mozayan C, Golanov EV, Ahn CH, Hartings JA, Narayan RK. Highly accurate thermal flow microsensor for continuous and quantitative measurement of cerebral blood flow. Biomed Microdevices 2015; 17:87. [DOI: 10.1007/s10544-015-9992-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
Traumatic brain injury (TBI) refers to a spectrum of brain injury that can result in significant morbidity and mortality in pediatric patients. Pediatric head trauma is distinct from adult TBI. The purpose of this review article is to discuss pediatric TBI and current treatment modalities available.
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Affiliation(s)
- Nicole Sharp
- Department of Surgery, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
| | - Kelly Tieves
- Department of Pediatrics, Critical Care Medicine, Children's Mercy Hospital and Clinics, Kansas City, Missouri, United States
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26
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Rostami E, Engquist H, Enblad P. Imaging of cerebral blood flow in patients with severe traumatic brain injury in the neurointensive care. Front Neurol 2014; 5:114. [PMID: 25071702 PMCID: PMC4083561 DOI: 10.3389/fneur.2014.00114] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 06/16/2014] [Indexed: 12/21/2022] Open
Abstract
Ischemia is a common and deleterious secondary injury following traumatic brain injury (TBI). A great challenge for the treatment of TBI patients in the neurointensive care unit (NICU) is to detect early signs of ischemia in order to prevent further advancement and deterioration of the brain tissue. Today, several imaging techniques are available to monitor cerebral blood flow (CBF) in the injured brain such as positron emission tomography (PET), single-photon emission computed tomography, xenon computed tomography (Xenon-CT), perfusion-weighted magnetic resonance imaging (MRI), and CT perfusion scan. An ideal imaging technique would enable continuous non-invasive measurement of blood flow and metabolism across the whole brain. Unfortunately, no current imaging method meets all these criteria. These techniques offer snapshots of the CBF. MRI may also provide some information about the metabolic state of the brain. PET provides images with high resolution and quantitative measurements of CBF and metabolism; however, it is a complex and costly method limited to few TBI centers. All of these methods except mobile Xenon-CT require transfer of TBI patients to the radiological department. Mobile Xenon-CT emerges as a feasible technique to monitor CBF in the NICU, with lower risk of adverse effects. Promising results have been demonstrated with Xenon-CT in predicting outcome in TBI patients. This review covers available imaging methods used to monitor CBF in patients with severe TBI.
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Affiliation(s)
- Elham Rostami
- Section of Neurosurgery, Department of Neuroscience, Uppsala University , Uppsala , Sweden ; Department of Neuroscience, Karolinska Institutet , Stockholm , Sweden
| | - Henrik Engquist
- Department of Surgical Sciences, Anaesthesiology and Intensive Care, Uppsala University , Uppsala , Sweden
| | - Per Enblad
- Section of Neurosurgery, Department of Neuroscience, Uppsala University , Uppsala , Sweden
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27
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Spaite DW, Bobrow BJ, Stolz U, Sherrill D, Chikani V, Barnhart B, Sotelo M, Gaither JB, Viscusi C, Adelson PD, Denninghoff KR. Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology. Acad Emerg Med 2014; 21:818-30. [PMID: 25112451 PMCID: PMC4134700 DOI: 10.1111/acem.12411] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 02/18/2014] [Accepted: 02/28/2014] [Indexed: 11/28/2022]
Abstract
Traumatic brain injury (TBI) exacts a great toll on society. Fortunately, there is growing evidence that the management of TBI in the early minutes after injury may significantly reduce morbidity and mortality. In response, evidence-based prehospital and in-hospital TBI treatment guidelines have been established by authoritative bodies. However, no large studies have yet evaluated the effectiveness of implementing these guidelines in the prehospital setting. This article describes the background, design, implementation, emergency medical services (EMS) treatment protocols, and statistical analysis of a prospective, controlled (before/after), statewide study designed to evaluate the effect of implementing the EMS TBI guidelines-the Excellence in Prehospital Injury Care (EPIC) study (NIH/NINDS R01NS071049, "EPIC"; and 3R01NS071049-S1, "EPIC4Kids"). The specific aim of the study is to test the hypothesis that statewide implementation of the international adult and pediatric EMS TBI guidelines will significantly reduce mortality and improve nonmortality outcomes in patients with moderate or severe TBI. Furthermore, it will specifically evaluate the effect of guideline implementation on outcomes in the subgroup of patients who are intubated in the field. Over the course of the entire study (~9 years), it is estimated that approximately 25,000 patients will be enrolled.
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Affiliation(s)
- Daniel W Spaite
- The Arizona Emergency Medicine Research Center, College of Medicine, The University of Arizona, Tucson, AZ; The Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson, AZ
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28
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Weil ZM, Gaier KR, Karelina K. Injury timing alters metabolic, inflammatory and functional outcomes following repeated mild traumatic brain injury. Neurobiol Dis 2014; 70:108-16. [PMID: 24983210 DOI: 10.1016/j.nbd.2014.06.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 06/05/2014] [Accepted: 06/22/2014] [Indexed: 01/04/2023] Open
Abstract
Repeated head injuries are a major public health concern both for athletes, and members of the police and armed forces. There is ample experimental and clinical evidence that there is a period of enhanced vulnerability to subsequent injury following head trauma. Injuries that occur close together in time produce greater cognitive, histological, and behavioral impairments than do injuries separated by a longer period. Traumatic brain injuries alter cerebral glucose metabolism and the resolution of altered glucose metabolism may signal the end of the period of greater vulnerability. Here, we injured mice either once or twice separated by three or 20days. Repeated injuries that were separated by three days were associated with greater axonal degeneration, enhanced inflammatory responses, and poorer performance in a spatial learning and memory task. A single injury induced a transient but marked increase in local cerebral glucose utilization in the injured hippocampus and sensorimotor cortex, whereas a second injury, three days after the first, failed to induce an increase in glucose utilization at the same time point. In contrast, when the second injury occurred substantially later (20days after the first injury), an increase in glucose utilization occurred that paralleled the increase observed following a single injury. The increased glucose utilization observed after a single injury appears to be an adaptive component of recovery, while mice with 2 injuries separated by three days were not able to mount this response, thus this second injury may have produced a significant energetic crisis such that energetic demands outstripped the ability of the damaged cells to utilize energy. These data strongly reinforce the idea that too rapid return to activity after a traumatic brain injury can induce permanent damage and disability, and that monitoring cerebral energy utilization may be a tool to determine when it is safe to return to the activity that caused the initial injury.
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Affiliation(s)
- Zachary M Weil
- Department of Neuroscience, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA.
| | - Kristopher R Gaier
- Department of Neuroscience, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Kate Karelina
- Department of Neuroscience, Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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Naqvi J, Yap KH, Ahmad G, Ghosh J. Transcranial Doppler ultrasound: a review of the physical principles and major applications in critical care. Int J Vasc Med 2013; 2013:629378. [PMID: 24455270 PMCID: PMC3876587 DOI: 10.1155/2013/629378] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2013] [Accepted: 11/10/2013] [Indexed: 12/28/2022] Open
Abstract
Transcranial Doppler (TCD) is a noninvasive ultrasound (US) study used to measure cerebral blood flow velocity (CBF-V) in the major intracranial arteries. It involves use of low-frequency (≤2 MHz) US waves to insonate the basal cerebral arteries through relatively thin bone windows. TCD allows dynamic monitoring of CBF-V and vessel pulsatility, with a high temporal resolution. It is relatively inexpensive, repeatable, and portable. However, the performance of TCD is highly operator dependent and can be difficult, with approximately 10-20% of patients having inadequate transtemporal acoustic windows. Current applications of TCD include vasospasm in sickle cell disease, subarachnoid haemorrhage (SAH), and intra- and extracranial arterial stenosis and occlusion. TCD is also used in brain stem death, head injury, raised intracranial pressure (ICP), intraoperative monitoring, cerebral microembolism, and autoregulatory testing.
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Affiliation(s)
- Jawad Naqvi
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
| | - Kok Hooi Yap
- Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
| | - Gulraiz Ahmad
- Royal Oldham Hospital, Rochdale Road, Manchester OL1 2JH, UK
| | - Jonathan Ghosh
- University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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30
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Lang SS, Kofke WA, Stiefel MF. Monitoring and intraoperative management of elevated intracranial pressure and decompressive craniectomy. Anesthesiol Clin 2012; 30:289-310. [PMID: 22901611 DOI: 10.1016/j.anclin.2012.05.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Elevated intracranial pressure can be caused by a variety of underlying conditions. Several physiologic and pharmacologic factors have a significant impact on intracranial hypertension, mostly caused by changes on cerebral blood volume, flow, and oxygenation. There are many therapies that can be used to decrease intracranial pressure ranging from pharmacologic to the surgical decompressive removal of the calvarium. Special consideration is made for the anesthetic management of these patients perioperatively.
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Affiliation(s)
- Shih-Shan Lang
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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31
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Abstract
Injury is a major cause of critical illness worldwide. Severely injured patients often require mechanical ventilation not only to manage primary respiratory failure but also as adjunct to manage other conditions. Injury induces fundamental changes in multiple organ systems which directly impact ventilator management; these changes are not shared by patients without concomitant tissue injury. In this article, we review the physiologic changes after injury and discuss the impact of injury on ventilator strategies and management. We also explore the special considerations in patients with traumatic brain injury, thermal injury, blast injury or bronchopleural fistula.
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Affiliation(s)
- Adrian A Maung
- Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University School of Medicine, New Haven, CT, USA
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Ragan DK, McKinstry R, Benzinger T, Leonard J, Pineda JA. Depression of whole-brain oxygen extraction fraction is associated with poor outcome in pediatric traumatic brain injury. Pediatr Res 2012; 71:199-204. [PMID: 22258132 PMCID: PMC3593145 DOI: 10.1038/pr.2011.31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a leading cause of death and disability in children. Metabolic failure is an integral component of the pathological aftermath of TBI. The oxygen extraction fraction (OEF) is a valuable parameter for characterization and description of metabolic abnormalities; however, OEF measurement has required either invasive procedures or the use of ionizing radiation, which significantly limits its use in pediatric research. RESULTS Patients with TBI had depressed OEF levels that correlated with the severity of injury. In addition, the OEF measured within 2 weeks of injury was predictive of patient outcome at 3 mo after injury. In pediatric TBI patients, low OEF-a marker of metabolic dysfunction-correlates with the severity of injury and outcome. DISCUSSION Our findings support previous literature on the role of metabolic dysfunction after TBI. METHODS Using a recently developed magnetic resonance (MR) technique for the measurement of oxygen saturation, we determined the whole-brain OEF in both pediatric TBI patients and in healthy controls. Injury and outcome were classified using pediatric versions of the Glasgow Coma Scale (GCS) and Glasgow Outcome Scale-Extended (GOS-E), respectively.
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Affiliation(s)
- Dustin K. Ragan
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
| | - Robert McKinstry
- Department of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Tammie Benzinger
- Department of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Jeffrey Leonard
- Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri
| | - Jose A. Pineda
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri,()
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Improvement of cerebral metabolism mediated by Ro5-4864 is associated with relief of intracranial pressure and mitochondrial protective effect in experimental brain injury. Pharm Res 2011; 28:2945-53. [PMID: 21584844 DOI: 10.1007/s11095-011-0463-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2011] [Accepted: 04/26/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE To investigate the possible impact of reduction of mitochondrial membrane permeabilization by modulation of the 18 kDa translocator protein mediated by Ro5-4864 over post-traumatic cerebral edema and metabolic crisis. METHODS Cerebral microdialysis and intracranial pressure (ICP) monitoring were performed in Sprague-Dawley rats treated by intraperitoneal injection of either dimethylsulfoxide (vehicle) or Ro5-4864 following cortical contusion and further correlated with quantitative assessment of mitochondrial damage, water content in the injured tissue, modified neurological severity score, and lesion size. RESULTS Ro5-4864 resulted in a profound decrease in ICP that correlated with improved cerebral metabolism characterized by significantly higher glucose and pyruvate and lower lactate concentrations in the pericontusional area in comparison with vehicle-treated animals. Reduced ICP correlated with reduced water content in the injured tissue; improved metabolism was associated with reduced mitochondrial damage evidenced by electron microscopy. Both effects were associated with a profound and significant reduction in glycerol release and lesion size, and correlated with improved neurological recovery. CONCLUSIONS The present study shows that Ro5-4864 has a favorable effect on the fate of injured brain, presumably mediated by improvement of metabolism. It further suggests that improvement of metabolism may contribute to ICP relief.
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Kim YJ. A systematic review of factors contributing to outcomes in patients with traumatic brain injury. J Clin Nurs 2011; 20:1518-32. [PMID: 21453293 DOI: 10.1111/j.1365-2702.2010.03618.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM AND OBJECTIVE To review, systematically, factors contributing to outcomes in patients with traumatic brain injury. BACKGROUND Traumatic brain injury is a leading cause of death and disability. Several studies have determined the significant predictors of outcomes after traumatic brain injury. The comprehensive identification of these reliable factors for traumatic brain injury is critical to both clinical practice and research. DESIGN Systematic literature review. METHODS Eligible studies that combined at least two variables to predict outcomes in patient with traumatic brain injury were identified via electronic database searches, footnote chasing and contact with clinical experts. Quality of selected studies was assessed in terms of internal and external validity using 15 questions. Two reviewers independently examined titles, abstracts and whether each met the predefined inclusion criteria. RESULTS A total of 46 studies which met review criteria were finally selected. Most studies satisfied internal validity in terms of validity of research variables and multivariate analysis, but few were validated externally. The following factors were significantly associated with unfavourable outcomes: sociodemographic factors such as older age, male gender, lower level of education; clinical factors such as lower Glasgow Coma Scale score, injury caused by motor vehicle crash, hypotension, hypoxia, increased intracranial pressure, no pupil reaction, hypo- or hyperglycaemia, anaemia, coagulopathy, hypo- or hyperthermia, abnormal level of electrolytes, duration of coma; higher level of computed tomography classification by Marshall category; type of intracerebral lesions. CONCLUSION Further studies on integrating the sociodemographic factors, the course of the clinical condition and a unified CT scoring system, are recommended for the evaluation and improvement of the prognosis of traumatic brain injury. RELEVANCE TO CLINICAL PRACTICE A systematic review of factors contributing to outcome for patients with traumatic brain injury will be invaluable in triage criteria, injury prognostication, care and discharge planning, resource use and patient and family counselling.
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Affiliation(s)
- Young-Ju Kim
- College of Nursing, Sungshin Women's University, Seoul, Korea.
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35
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Abstract
BACKGROUND The prevalence of persistent vegetative state (PVS) is estimated to be 40 to 168 per million person-years in the United States. Studies in the industrialized world have shown that the quality of life of persons with PVS is severely compromised and with paucity of data on treatment of persons with PVS. This is the first time a report of treatment of PVS with a known medication is being reported from Nigeria or sub-Saharan Africa. Our objectives were to prospectively follow up some cohorts of patients diagnosed to have PVS by a reliable and valid criteria and to look out for any response to L-dopa/carbidopa administration. DESIGN This was a prospective case series. SETTING The study was performed from a tertiary center. METHODS We adopted the Multisociety Task Force of the American Academy of Neurology diagnostic criteria for PVS and minimally conscious state, and the Royal College of Physicians differential diagnostic criteria were used to include patients for the study. We also carried out detailed neurological examination of the unconscious patient to include or exclude subjects for the study. RESULTS For the outcome measure, we adopted the ASPEN working group criteria for minimally conscious state. After 2 to 5 months of administration of L-dopa/carbidopa; 4 patients (4 = 36.4%) showed significant clinical improvement. Two (2 = 18.2%) who did not improve eventually died. One case (case 5) died after a second bleed. CONCLUSION There were some remarkable responses to L-dopa/carbidopa after about 2 to 6 months of therapy.
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36
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Zink BJ, Szmydynger-Chodobska J, Chodobski A. Emerging concepts in the pathophysiology of traumatic brain injury. Psychiatr Clin North Am 2010; 33:741-56. [PMID: 21093676 DOI: 10.1016/j.psc.2010.08.005] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
A complex set of molecular and functional reactions is set into motion by traumatic brain injury (TBI). New research that extends beyond pathological effects on neurons suggests a key role for the blood-brain barrier, neurovascular unit, arginine vasopressin, and neuroinflammation in the pathophysiology of TBI. The prevalence of molecular derangements in TBI holds promise for the identification and use of biomarkers to assess severity of injury, determine prognosis, and perhaps direct therapy. Hopefully, improved knowledge of these elements of pathophysiology will provide the mechanistic clues that lead to improved treatment of TBI.
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Affiliation(s)
- Brian J Zink
- Department of Emergency Medicine, Alpert Medical School of Brown, University Rhode Island Hospital & The Miriam Hospital, 593 Eddy Street, Claverick 2, Providence, RI 02903, USA.
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Spiotta AM, Stiefel MF, Gracias VH, Garuffe AM, Kofke WA, Maloney-Wilensky E, Troxel AB, Levine JM, Le Roux PD. Brain tissue oxygen-directed management and outcome in patients with severe traumatic brain injury. J Neurosurg 2010; 113:571-80. [PMID: 20415526 DOI: 10.3171/2010.1.jns09506] [Citation(s) in RCA: 183] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECT The object of this study was to determine whether brain tissue oxygen (PbtO(2))-based therapy or intracranial pressure (ICP)/cerebral perfusion pressure (CPP)-based therapy is associated with improved patient outcome after severe traumatic brain injury (TBI). METHODS Seventy patients with severe TBI (postresuscitation GCS score < or = 8), admitted to a neurosurgical intensive care unit at a university-based Level I trauma center and tertiary care hospital and managed with an ICP and PbtO(2) monitor (mean age 40 +/- 19 years [SD]) were compared with 53 historical controls who received only an ICP monitor (mean age 43 +/- 18 years). Therapy for both patient groups was aimed to maintain ICP < 20 mm Hg and CPP > 60 mm Hg. Patients with PbtO(2) monitors also had therapy to maintain PbtO(2) > 20 mm Hg. RESULTS Data were obtained from 12,148 hours of continuous ICP monitoring and 6,816 hours of continuous PbtO(2) monitoring. The mean daily ICP and CPP and the frequency of elevated ICP (> 20 mm Hg) or suboptimal CPP (< 60 mm Hg) episodes were similar in each group. The mortality rate was significantly lower in patients who received PbtO(2)-directed care (25.7%) than in those who received conventional ICP and CPP-based therapy (45.3%, p < 0.05). Overall, 40% of patients receiving ICP/CPP-guided management and 64.3% of those receiving PbtO(2)-guided management had a favorable short-term outcome (p = 0.01). Among patients who received PbtO(2)-directed therapy, mortality was associated with lower mean daily PbtO(2) (p < 0.05), longer durations of compromised brain oxygen (PbtO(2) < 20 mm Hg, p = 0.013) and brain hypoxia (PbtO(2) < 15 mm Hg, p = 0.001), more episodes and a longer cumulative duration of compromised PbtO(2) (p < 0.001), and less successful treatment of compromised PbtO(2) (p = 0.03). CONCLUSIONS These results suggest that PbtO(2)-based therapy, particularly when compromised PbtO(2) can be corrected, may be associated with reduced patient mortality and improved patient outcome after severe TBI.
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Affiliation(s)
- Alejandro M Spiotta
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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38
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Georgoff P, Meghan S, Mirza K, Stein SC. Geographic Variation in Outcomes from Severe Traumatic Brain Injury. World Neurosurg 2010; 74:331-45. [DOI: 10.1016/j.wneu.2010.03.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Accepted: 03/13/2010] [Indexed: 01/01/2023]
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Soustiel JF, Sviri GE, Mahamid E, Shik V, Abeshaus S, Zaaroor M. Cerebral Blood Flow and Metabolism Following Decompressive Craniectomy for Control of Increased Intracranial Pressure. Neurosurgery 2010; 67:65-72; discussion 72. [DOI: 10.1227/01.neu.0000370604.30037.f5] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Decompressive craniectomy (DC) is a common practice for control of intracranial pressure (ICP) following traumatic brain injury (TBI), although the impact of this procedure on the fate of operated patients is still controversial.
METHODS
Cerebral blood flow (CBF) and metabolic rates were monitored prospectively and daily as a surrogate of neuronal viability in 36 TBI patients treated by DC and compared with those of 86 nonoperated patients. DC was performed either on admission (n = 29) or within 48 hours of admission (n = 7).
RESULTS
DC successfully controlled ICP levels and maintained CBF within a normal range although the cerebral metabolic rate of oxygen (CMRO2) was significantly lower in this group. In 7 patients, pre- and postoperative recordings showed a significant ICP decrease that correlated with CBF augmentation but not with concurrent improvement of CMRO2 that remained particularly low. Logistic regression analysis of all investigated variables showed that DC was not associated with higher mortality despite more severe injuries in this group. However, operated patients were 7-fold more likely to have poor functional outcomes than nonoperated patients. Good functional outcome was strongly associated with higher CMRO2 but not with higher CBF values. CMRO2 levels were significantly lower in the DC group, even after adjustment for injury severity, and showed a progressive and sustained trend of deterioration significantly different from that of the non-DC group.
CONCLUSION
These results suggest that DC may enhance survival in the presence of severe brain swelling, although it is unlikely to represent an adequate answer to mitochondrial damage responsible for cellular energy crisis and edema.
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Affiliation(s)
| | - Gill E. Sviri
- Department of Neurosurgery, Rambam Medical Center, Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel
| | - Eugenia Mahamid
- Department of Neurosurgery, Rambam Medical Center, Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel
| | - Veniamin Shik
- Department of Neurosurgery, Rambam Medical Center, Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel
| | - Sergey Abeshaus
- Department of Neurosurgery, Rambam Medical Center, Faculty of Medicine, The Technion-Israel Institute of Technology, Haifa, Israel
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40
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41
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Xu XY, Liu WG, Yang XF, Li LQ. Evaluation of models that predict short-term outcome after traumatic brain injury. Brain Inj 2009; 21:575-82. [PMID: 17577708 DOI: 10.1080/02699050701426881] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
PRIMARY OBJECTIVE This study aimed to identify models that predicted the short-term outcome after traumatic brain injury (TBI) from the literature and to evaluate their clinical significance. METHODS Literatures from PubMED were reviewed. Regression coefficients and intercepts were extracted. A group of 229 cases was used for validation and the unfavourable rate was calculated to assess the validity of these models by the area under receiver operating. Characteristic curve (AUC), C-statistic and Brier score. MAIN RESULTS In total, 13 studies of 18 different models were included. Data from the validation group were in accordance with the indicators of the studies reviewed. All models got an AUC value ranging from 0.644-0.890 except two (AUC value <0.6) and their Brier scores were near zero. However, the calibration of most studies was insufficient (p < 0.05). CONCLUSIONS Most of the models included in this study have a good discriminatory power while lacking sufficient calibration. However, they all predict with relative accuracy at the level of individuals. Therefore, current models can be used to predict the survival rate of individual patients and may be useful to inform patients and relatives about the likelihood of a beneficial outcome.
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Affiliation(s)
- Xiao Yan Xu
- Department of Neurosurgery, Zhejiang University, Hangzhou, Zhejiang Province, PR China
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43
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Abstract
Head injury remains a major cause of preventable death and serious morbidity in young adults. Based on the available evidence, it appears that a cerebral perfusion pressure of 50 to 70 mm Hg is generally adequate to ensure cerebral oxygen delivery and prevent ischemia. However, evidence suggests that perfusion requirements may not only vary across the injured brain but also differ depending on the time since injury. Such heterogeneity, both within and between subjects, suggests that individualized therapy may be an appropriate treatment strategy. Future studies should aim to assess which groups of patients, and what regional pathophysiological derangements, may benefit with improvements in functional outcome from therapeutic increases or decreases in cerebral perfusion pressure beyond these proposed limits. Such functional improvements may be of immense importance to patients and require formal neurocognitive assessments to discriminate improvements.
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Affiliation(s)
- Monica Trivedi
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Kollmar R, Georgiadis D, Schwab S. Alpha-stat versus pH-stat guided ventilation in patients with large ischemic stroke treated by hypothermia. Neurocrit Care 2008; 10:173-80. [PMID: 19002612 DOI: 10.1007/s12028-008-9162-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Accepted: 10/14/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Moderate hypothermia (MH) is a therapeutic approach for ischemic stroke as well as cardiac arrest. Two different technical strategies of ventilation during MH called alpha- and pH-stat dramatically influence cerebral blood flow (CBF). In turn this might influence neuronal damage and intracranial pressure (ICP). Therefore, effects of ventilation on CBF and ICP were measured in patients undergoing MH because of large ischemic stroke to address optimal ventilation management. METHODS Eight patients (n = 8) with large ischemic stroke in the territory of the middle cerebral artery (MCA) were treated by MH of 33 degrees C within 24 h after symptom onset. MH was applied at least for 72 h. Each day, patients were ventilated repetitively with either alpha-stat or pH-stat for 60 min periods. Alpha-stat was applied between the measurements. ICP, CBF, and mean arterial blood pressure (MABP) were measured. The xenon clearance method was used to assess CBF at the bedside. RESULTS There were no significant differences between ICP values for alpha-stat or pH-stat during days 1 and 2 after induction of hypothermia. However, ICP was higher in the pH- as compared to the alpha-stat group (P < 0.05) and exceeded a mean of 20 mmHg on day 3. pH-stat led to a significant increase of CBF in all measures (P < 0.05), while MABP was unaffected. CONCLUSIONS pH-stat implies a better CBF to the injured brain, while it might be dangerous by elevating ICP in more subacute stages.
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Affiliation(s)
- Rainer Kollmar
- Department of Neurology, University Hospital Erlangen, University of Erlangen, Schwabachanlage 6, Erlangen 91054, Germany.
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45
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Stevens RD, Lazaridis C, Chalela JA. The Role of Mechanical Ventilation in Acute Brain Injury. Neurol Clin 2008; 26:543-63, x. [DOI: 10.1016/j.ncl.2008.03.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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46
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Kofke WA, Stiefel M. Monitoring and intraoperative management of elevated intracranial pressure and decompressive craniectomy. Anesthesiol Clin 2008; 25:579-603, x. [PMID: 17884709 DOI: 10.1016/j.anclin.2007.05.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are numerous clinical scenarios wherein a critically ill patient may present with neurologic dysfunction. In a general sense these scenarios often involve ischemia, trauma, or neuroexcitation. Each of these may include a period of decreased cerebral perfusion pressure, usually due to elevated intracranial pressure (ICP), eventually compromising cerebral blood flow sufficiently to produce permanent neuronal loss, infarction, and possibly brain death. Elevated ICP is thus a common pathway for neural demise and it may arise from a variety of causes, many of which may result in a neurosurgical procedure intended to ameliorate the impact or etiology of elevated ICP.
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Affiliation(s)
- W Andrew Kofke
- Department of Anesthesia and Critical Care, University of Pennsylvania, 3400 Spruce St., Dulles 7, Philadelphia, PA 19104, USA.
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47
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Soustiel JF, Sviri GE. Monitoring of cerebral metabolism: non-ischemic impairment of oxidative metabolism following severe traumatic brain injury. Neurol Res 2008; 29:654-60. [PMID: 18173902 DOI: 10.1179/016164107x240017] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE To investigate and compare the respective dynamics of cerebral blood flow (CBF) and metabolism in response to changes in neurological condition and intracranial pressure (ICP) in severe traumatic brain injury (TBI). METHODS Eight-four patients with severe TBI were prospectively enrolled in this study. CBF was measured daily and global cerebral metabolic rates of oxygen (CMRO(2)), glucose (CMRGlc) and lactate (CMRLct) were calculated using arterial jugular differences. In addition, 33 patients had a second evaluation shortly after a significant change (>5 mmHg) in their ICP. RESULTS Eight hundred and ninety-four evaluations were collected during a period ranging between 1 and 12 days (mean: 5.1 +/- 2.6 days). CBF was moderately but significantly decreased. Oppositely, CMRO(2) was profoundly reduced with evidence for critical metabolic failure (<1.2 ml/100 g/min) in 30.5% whereas only 8.5% of CBF measurements were lower than 20 ml/100 g/min. Furthermore, in 78 instances of a dynamic assessment performed following ICP increase (n = 20) or decrease (n = 58), CMRO(2) but not CBF proved to be significantly and inversely affected by ICP fluctuations. Finally, CMRO(2) and CMRLct correlated with GCS score in contrast with CBF. Both CBF and metabolic indices, however, correlated with neurological outcome. CONCLUSION This study shows that cerebral metabolic failure following TBI is a common finding that is not of ischemic origin in most instances. Unlike frequently assumed, cerebral metabolism is not constrained within the narrow range of a static depression sustained for weeks but rather subject to significant variations in response to changes in ICP or neurological condition.
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Affiliation(s)
- Jean F Soustiel
- Department of Neurosurgery, Rambam Medical Center, Faculty of Medicine, Technion, Israel Institute of Technology, Haifa 31096, Israel.
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48
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The accuracy of jugular bulb venous monitoring in detecting cerebral ischemia in awake patients undergoing carotid endarterectomy. J Neurosurg Anesthesiol 2008; 20:8-14. [PMID: 18157019 DOI: 10.1097/ana.0b013e31814b1459] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
To investigate the accuracy of jugular bulb venous monitoring in detecting cerebral ischemia, we performed ipsilateral jugular bulb venous monitoring in 48 patients undergoing carotid surgery under regional anesthesia. Cerebral ischemia was assumed when neurologic deterioration occurred. During carotid clamping, the maximal arterial-jugular venous oxygen content difference [AJDO2 (max)], the minimal jugular venous oxygen saturation [SjO2 (min)], the maximal arterial-jugular venous lactate content difference [AJDL (max)], the maximal lactate oxygen index [LOI (max)], and the maximal modified LOI [mLOI (max)] were determined. To quantify the selectivity of each parameter, we performed receiver operating characteristic analysis and determined the area under the curve. The cutoff points providing the highest accuracy and the corresponding sensitivity (Se) and specificity (Spec) were determined. Neurologic deterioration occurred in 12 patients. All parameters, except AJDO2 (max), showed significant ability to distinguish between ischemic and nonischemic patients. The area under the curve for AJDL (max) was 0.840, for SjO2 (min) 0.766, for LOI 0.745, for mLOI 0.748, and for AJDO2 (max) 0.672. We found cutoff points of > or =0.16 mmol/L for AJDL (max) (Se=67%; Spec=86%) and < or =55% for SjO2 (Se=75%; Spec=83%). In conclusion, the present investigation shows that AJDL, SjO2, LOI, and mLOI provide the ability to detect cerebral hypoperfusion. The highest accuracy was found for AJDL. Neither the calculation of LOI nor of mLOI showed improved results.
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Dusick JR, Glenn TC, Lee WNP, Vespa PM, Kelly DF, Lee SM, Hovda DA, Martin NA. Increased pentose phosphate pathway flux after clinical traumatic brain injury: a [1,2-13C2]glucose labeling study in humans. J Cereb Blood Flow Metab 2007; 27:1593-602. [PMID: 17293841 DOI: 10.1038/sj.jcbfm.9600458] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Patients with traumatic brain injury (TBI) routinely exhibit cerebral glucose uptake in excess of that expected by the low levels of oxygen consumption and lactate production. This brings into question the metabolic fate of glucose. Prior studies have shown increased flux through the pentose phosphate cycle (PPC) during cellular stress. This study assessed the PPC after TBI in humans. [1,2-(13)C(2)]glucose was infused for 60 mins in six consented, severe-TBI patients (GCS<9) and six control subjects. Arterial and jugular bulb blood sampled during infusion was analyzed for (13)C-labeled isotopomers of lactate by gas chromatography/mass spectroscopy. The product of lactate concentration and fractional abundance of isotopomers was used to determine blood concentration of each isotopomer. The difference of jugular and arterial concentrations determined cerebral contribution. The formula PPC=(m1/m2)/(3+(m1/m2)) was used to calculate PPC flux relative to glycolysis. There was enrichment of [1,2-(13)C(2)]glucose in arterial-venous blood (enrichment averaged 16.6% in TBI subjects and 28.2% in controls) and incorporation of (13)C-label into lactate, showing metabolism of labeled substrate. The PPC was increased in TBI patients relative to controls (19.6 versus 6.9%, respectively; P=0.002) and was excellent for distinguishing the groups (AUC=0.944, P<0.0001). No correlations were found between PPC and other clinical parameters, although PPC was highest in patients studied within 48 h of injury (averaging 33% versus 13% in others; P=0.0006). This elevation in the PPC in the acute period after severe TBI likely represents a shunting of substrate into alternative biochemical pathways that may be critical for preventing secondary injury and initiating recovery.
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Affiliation(s)
- Joshua R Dusick
- Division of Neurosurgery and Cerebral Blood Flow Laboratory, University of California at Los Angeles, Los Angeles, California 90095-7039, USA
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50
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Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, Hartl R, Manley GT, Nemecek A, Newell DW, Rosenthal G, Schouten J, Shutter L, Timmons SD, Ullman JS, Videtta W, Wilberger JE, Wright DW. Guidelines for the management of severe traumatic brain injury. XIV. Hyperventilation. J Neurotrauma 2007; 24 Suppl 1:S87-90. [PMID: 17511553 DOI: 10.1089/neu.2007.9982] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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