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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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Bonfanti M, Lorini FL, Zangari R, Bonanomi E, Farina A, Pezzetti G, Gerevini S, Aresi S, Dell'Avanzo G, Micheli F, Lanterna LA, Biroli F, Gritti P. Intracranial Pressure Thresholds for Cerebral Autoregulation Impairment: Age-Stratified Analysis of Ultra-Low-Frequency Pressure Reactivity Index (UL-PRx) in Traumatic Brain Injury. Neurocrit Care 2025; 42:152-163. [PMID: 39009939 DOI: 10.1007/s12028-024-02056-5] [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: 03/20/2024] [Accepted: 06/21/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND The study investigated the effectiveness of low-frequency sampling in detecting alterations in cerebrovascular reactivity (CVR) associated with changes in intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across different age groups. The primary objective was to investigate an ICP threshold that indicates a decrease in CVR as evidenced by a significant increase in the ultra-low-frequency pressure reactivity index (UL-PRx). Additionally, the study aimed to develop an age-based categorization method for patients with TBI to investigate the differences between these ICP thresholds in different age groups. METHODS In this retrospective analysis, data from 263 patients with TBI were prospectively collected. ICP and mean arterial pressure were extracted from the hospital database at 5-min intervals. Demographic details, clinical presentation, computed tomography scans, neurosurgical interventions, and 12-months outcome were recorded. ICP versus UL-PRx values were categorized into ICP bins and graphically represented with boxplots for each age group, illustrating how as ICP values rise, there is a bin (age-tailored ICP [AT-ICP]) beyond which UL-PRx shows a sudden increase, indicating CVR loss. Homogeneous age groups were established to obtain a consistent AT-ICP threshold. The discriminatory ability of the AT-ICP thresholds was compared with the guideline-recommended thresholds by calculating the area under the Receiver Operating Characteristic curve of the ICP-derived indices (dose above threshold, and the hourly dosage above threshold). RESULTS Age groups 0-5, 6-20, 21-60, 61-70, and 71-85 years were the best age subdivisions, corresponding to AT-ICP thresholds of 20, 30, 35, 25, and 30 mmHg, respectively. The AT-ICP thresholds exhibited better discriminative ability compared with the guideline-recommended thresholds. CONCLUSIONS The AT-ICP thresholds offer a novel approach for estimating CVR impairment and the developed method represents an alternative solution to address the age stratification issue in patients with TBI.
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Affiliation(s)
- Marco Bonfanti
- FROM Research Foundation- ETS, Papa Giovanni XXIII Hospital, Piazza OSM 1, 24129, Bergamo, Italy.
| | - Ferdinando Luca Lorini
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rosalia Zangari
- FROM Research Foundation- ETS, Papa Giovanni XXIII Hospital, Piazza OSM 1, 24129, Bergamo, Italy
| | - Ezio Bonanomi
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessia Farina
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giulio Pezzetti
- Department of Neuroradiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Simonetta Gerevini
- Department of Neuroradiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Silvia Aresi
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giacomo Dell'Avanzo
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fabio Micheli
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Francesco Biroli
- FROM Research Foundation- ETS, Papa Giovanni XXIII Hospital, Piazza OSM 1, 24129, Bergamo, Italy
| | - Paolo Gritti
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
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3
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Ghaziani E, Petersen M, Olsen MH, Korshøj AR, Dyrskog S, Bernhardt J, Frisvold SK, Sundstrøm T, Sandrød O, Møller K, Alvsåker K, Godbolt AK, Riberholt CG. First out-of-bed mobilisation in adults with severe acquired brain injury in Scandinavian neurointensive care units: A survey of current clinical practice (FOOBScan). Acta Anaesthesiol Scand 2025; 69:e14574. [PMID: 39788872 DOI: 10.1111/aas.14574] [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: 07/12/2024] [Revised: 11/16/2024] [Accepted: 12/25/2024] [Indexed: 01/12/2025]
Abstract
BACKGROUND The harm-benefit balance for early out-of-bed mobilisation of patients with severe acquired brain injury (ABI) in neurointensive care units (neuro-ICUs) is unclear, and there are no clinical guidelines. This study aimed to survey the current clinical practice and perceptions among clinicians involved in first out-of-bed mobilisation in Scandinavian neuro-ICUs. METHODS This was a cross-sectional, anonymous, web-based survey; the reporting follows the recommended CROSS checklist. Clinicians involved in the first out-of-bed mobilisation in all 14 Scandinavian neuro-ICUs were eligible to participate. The questionnaire was distributed to local contact persons. Respondents were asked about their clinical practice regarding the first out-of-bed mobilisation, and perceived harms and benefits of early mobilisation. RESULTS One hundred eighty clinicians (53% nurses, 31% physicians, and 14% therapists) completed the questionnaire. Eighty-one percent indicated that more than half of patients underwent their first out-of-bed mobilisation in the neuro-ICU. More respondents from Denmark than the remaining countries indicated that both physicians, nurses and physiotherapists contributed to the decision on when to mobilise. Intracranial pressure, cerebral perfusion pressure, sedation, presence of vasospasm and arterial blood pressure were the most used safety clinical indicators for deciding about mobilisation. Clinicians stated several positive effects of mobilisation, for example, improved bowel movements, level of consciousness, motor function, and reduced risk of pneumonia, contractures, delirium, and deep vein thrombosis. CONCLUSIONS Mobilisation out of bed is frequently performed in patients with severe ABI in Scandinavian neuro-ICUs. The perceived clinical safety indicators for mobilisation were ICP, CPP, level of sedation, presence of vasospasms, and ABP.
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Affiliation(s)
- Emma Ghaziani
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Merete Petersen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Rosendal Korshøj
- Department of Neurosurgery & Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Stig Dyrskog
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Bernhardt
- The Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
| | | | - Terje Sundstrøm
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Oddrun Sandrød
- Department of Intensive Care Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
| | - Kristin Alvsåker
- Postoperative and Intensive Care Department, Oslo University Hospital, Oslo, Norway
| | - Alison K Godbolt
- Karolinska Institutet Danderyds Sjukhus, University Department of Rehabilitation Medicine, Stockholm, Sweden
| | - Christian Gunge Riberholt
- Department of Brain and Spinal Cord Injury, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Robba C, Giardiello D, Almondo C, Asehnoune K, Badenes R, Cinotti R, Elhadi M, Graziano F, Helbok R, Jiang L, Chen W, Laffey JG, Messina A, Putensen C, Schultz MJ, Wahlster S, Rebora P, Galimberti S, Taccone FS, Citerio G, VENTIBRAIN study group. Ventilation practices in acute brain injured patients and association with outcomes: the VENTIBRAIN multicenter observational study. Intensive Care Med 2025; 51:318-331. [PMID: 39992441 PMCID: PMC11903615 DOI: 10.1007/s00134-025-07808-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2024] [Accepted: 01/19/2025] [Indexed: 02/25/2025]
Abstract
PURPOSE Current mechanical ventilation practices for patients with acute brain injury (ABI) are poorly defined. This study aimed to describe ventilator settings/parameters used in intensive care units (ICUs) and evaluate their association with clinical outcomes in these patients. METHODS An international, prospective, multicenter, observational study was conducted across 74 ICUs in 26 countries, including adult patients with ABI (e.g., traumatic brain injury, intracranial hemorrhage, subarachnoid hemorrhage, and acute ischemic stroke), who required ICU admission and invasive mechanical ventilation. Ventilatory settings were recorded daily during the first week and on days 10 and 14. ICU and 6-months mortality and 6-months neurological outcome were evaluated. RESULTS On admission, 2095 recruited patients (median age 58 [interquartile range 45-70] years, 66.1% male) had a median plateau pressure (Pplat) of 15 (13-18) cmH20, tidal volume/predicted body weight 6.5 (5.7-7.3) mL/Kg, driving pressure 9 (7-12) cmH20, and positive end-expiratory pressure 5 (5-8) cmH20, with no modifications in case of increased intracranial pressure (> 20 mmHg). Significant differences in practices were observed across different countries. The majority of these ventilatory settings were associated with ICU mortality, with the highest hazard ratio (HR) for Pplat (odds ratio 1.50; 95% confidence interval, CI: 1.27-1.78). The results demonstrated consistent association with 6-month mortality; less clear association was observed for neurological outcome. CONCLUSIONS Protective ventilation strategies are commonly used in ABI patients but with high variability across different countries. Ventilator settings during ICU stay were associated with an increased risk of ICU and 6-month mortality, but not an unfavorable neurological outcome.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy.
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy.
| | - Daniele Giardiello
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Chiara Almondo
- Department of Surgical Science and Integrated Diagnostic, University of Genova, Genoa, Italy
| | - Karim Asehnoune
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, Nantes, France
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - Raphael Cinotti
- Department of Anaesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, Nantes, France
| | | | - Francesca Graziano
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lidan Jiang
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - Wenjin Chen
- Department of Neurosurgery, XuanWu Hospital, Capital Medical University, Beijing, China
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, University Hospital Galway, University of Galway, Galway, Ireland
| | - Antonio Messina
- Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Marcus J Schultz
- Department of Clinical Medicine, University of Oxford Nuffield, Oxford, UK
- Department of Intensive Care, Amsterdam University Medical Centers, Location 'AMC', Amsterdam, The Netherlands
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Mahidol University, Bangkok, Thailand
- Department of Anesthesia, General Intensive Care and Pain Management, Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Medical University of Vienna, Vienna, Austria
| | - Sarah Wahlster
- Departments of Neurology, Neurosurgery, and Anesthesiology, University of Washington, Seattle, USA
| | - Paola Rebora
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italia
| | - Stefania Galimberti
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italia
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italia
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Collaborators
Chenggong Hu, Tingting Liu, Meiling Dong, Wei Yang, Ying Yang, Yinxia Lv, Hongtao Xia, Bangguo Zhang, Qionglan Dong, Dan Xu, Yunxing Cao, Natalie L Smith, Nassim S Matin, Adrienne James, Abhijit V Lele, James A Town, Stefan Ehrentraut, Felix Lehmann, Stefan Kreyer, Thomas Muders, Jens Poth, Yvonne Klevenhaus, Andrea Sauer, Christian Bode, Konrad Peukert, Qibing Huang, Zeli Zhang, Shoujia Sun, Min Xu, Kun Yang, Ruifang She, Ben Sang, Liangpeng Song, Lisheng Wu, Liang Wu, Heng Zhang, Liqing Bi, Jingmei Wang, Yong Li, Ziyue Wang, Guang Feng, Yangong Chao, Giulia Ciparelli, Nicoló Patroniti, Nicoló Patroniti, Camilla Paolessi, Carlotta Bandoni, Maura Mandelli, Gianni Ciabatti, Patrick Rusagara, Vanni Orzalesi, Luca Bucciardini, Fabio Picciafuochi, Alessandra De Luca, Elena Torrini, Laura Cosenza, Maria Amigoni, Paolo Mangili, Valentina Piazza, Melisa Juliana Polo Friz, Silvia Del Bianco, Margherita Valla, Giorgia Ogliari, Alberto Addis, Jorge H Mejía-Mantilla, Leidy Gaviria Villarreal, Ángela Marulanda, José Luis Aldana, Luis Figueroa, Leidy Johanna Bolaños, Jackeline Vivas, Diana Marcela Londoño, Vincent Legros, Thierry Floch, Marion Leclercq-Rouget, Pierre-Antoine Seube-Remy, Lison Menage-Innocenti, Cindy Chauchard, Francesca Fossi, Arturo Chieregato, Federico Pozzi, Cristiana Cipolla, Anna Bortolaso, Linda Bosa, Antonella Cotoia, Tecla Zimotti, Filippo Di Pierro, Davide Correnti, Luciano Napolitano, Giuseppe Ferrara, Abele Donati, Vincenzo Gabbanelli, Lucia Pesaresi, Giulia Mariotti, Evdokia Gavrielatou, Konstantinos Gkirgkiris, Vasileios Grigoropoulos, Ilias Siempos, Anna Lindner, Verena Rass, Philipp Kindl, Lauma Putnina, Maurizio Cecconi, Federico Villa, Daniele Bono, Andrea Cortegiani, Giulia Ingoglia, Santi Maurizio Raineri, Mariachiara Ippolito, Feng Wei, Ao Jiao, Sami Sannoufa, Mhd Noor Tahawi, Mohammad Eyad Takahji, Chiarini Valentina, Cavagna Silvia, Gamberini Lorenzo, Joana Ferreira, Dário Batista, Yannick Hourmant, Antoine Roquilly, Raphaël Cinotti, Katharina Krenn, Alessia Felli, Petra Hobart, Essam Eldien Abuobaida Banaga Haj Eltayeb, Hayat Abuobaida Bannaga, Ubay Abdullah Kareem Allah Alday, Lochner Piergiorgio, Beomonte Zobel Michele, Harajdova Estera, Domenico Gelormini, Marilena Casartelli Liviero, Leonardo Gottin, Berta Monleón, Nekane Romero-García, Hussam Elmelliti, Phool Iqbal, Foziya Solanki, Ahmed Lutfe Abdussalam, Amr Elwany, Mohamed Shemeis, AbdulRhman Alaa, Reem Hunain, Shwethapriya Rao, Zehra Siddiqui, Juan Olivella-Gomez, Emilio Viñán-Garcés, Anselmo Caricato, Luca Pisapia, Camilla Gelormini, Pouya Tahsili-Fahadan, Jing Wang, Naveen M Altaweel, Fabio Micheli, Paolo Gritti, Clotilde Schilte, Gilles Francony, Vera Spatenkova, Ondrej Brandejs, Hang Chen, Minli Chen, Guang Feng, Yanru Li, Reng Ren, Carlos Ferrando, Luigi Zattera, Claudia de Peray, Anna Recasens, Mohamed Elbahnasawy, Mohamed Nasreddin, Mohamed Shama, Min Zhou, Rui Tang, Nitin Manohara, Mukilan Balasubramanian, Isaac Babu, Ciara Hanley, Ciprian Nita, Reem Elsaadany, Wen Wu, Yman Majdi Ibrahim Mohammed, Saifaleslam Elsahli, Aiman Al-Touny, Mohammed Alsharif, Andreja Möller Petrun, Gemma Gomà, Manuel J Rivera-Chávez, Sung-Min Cho, Matthew Bower, Jose I Suarez, Jinfang Liu, Maytham A Al-Juaifari, Dietrich Henzler, Almu'atasim Khamees, Tania Huanca Felipez, Bourhan Mohammad Hassan Alrayes, Shuhan Cai, Daniel Godoy,
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Dengler B, McCafferty R, Neal C, Bell R, Sonka BJ, Jensen S, Tadlock MD, Van Gent JM, How RA, Gurney J. A Joint Trauma System Clinical Practice Guideline: Traumatic Brain Injury Management and Basic Neurosurgery in the Deployed Environment. Mil Med 2025; 190:124-134. [PMID: 38877894 DOI: 10.1093/milmed/usae298] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 05/22/2024] [Indexed: 01/18/2025] Open
Abstract
Management of the patient with moderate to severe brain injury in any environment can be time consuming and resource intensive. These challenges are magnified while forward deployed in austere or hostile environments. This Joint Trauma System Clinical Practice Guideline provides recommendations for the treatment and medical management of casualties with moderate to severe head injuries in an environment where personnel, resources, and follow-on care are limited. These guidelines have been developed by acknowledging commonly recognized recommendations for neurosurgical and neuro-critical care patients and augmenting those evaluations and interventions based on the experience of neurosurgeons, trauma surgeons, and intensivists who have delivered care during recent coalition conflicts.
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Affiliation(s)
- Bradley Dengler
- Military Traumatic Brain Injury Initiative (MTBI2), Bethesda, MD 20814, USA
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Randall McCafferty
- Department of Neurosurgery, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX 78234, USA
| | - Christopher Neal
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Randy Bell
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA
| | - Brian J Sonka
- Joint Trauma System, JBSA Fort Sam Houston, TX 78234-6315, USA
| | - Shane Jensen
- Joint Trauma System, JBSA Fort Sam Houston, TX 78234-6315, USA
- San Antonio Uniformed Services Health Education Consortium, Joint Base San Antonio-Fort Sam Houston, TX 7234, USA
| | - Matthew D Tadlock
- Joint Trauma System, JBSA Fort Sam Houston, TX 78234-6315, USA
- Department of Surgery, Naval Medical Center San Diego, Uniformed Services University of the Health Sciences, San Diego, CA 92134, USA
| | | | - Remealle A How
- Joint Trauma System, JBSA Fort Sam Houston, TX 78234-6315, USA
- Baltimore C-STARS, USAFSAM, R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD 21201, USA
| | - Jennifer Gurney
- Joint Trauma System, JBSA Fort Sam Houston, TX 78234-6315, USA
- Department of Surgery, San Antonio Military Medical Center, JBSA Fort Sam Houston, TX 78234, USA
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Uryga A, Mataczyński C, Pelah AI, Burzyńska M, Robba C, Czosnyka M. Exploration of simultaneous transients between cerebral hemodynamics and the autonomic nervous system using windowed time-lagged cross-correlation matrices: a CENTER-TBI study. Acta Neurochir (Wien) 2024; 166:504. [PMID: 39680255 PMCID: PMC11649841 DOI: 10.1007/s00701-024-06375-6] [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: 10/11/2024] [Accepted: 11/20/2024] [Indexed: 12/17/2024]
Abstract
BACKGROUND Traumatic brain injury (TBI) can significantly disrupt autonomic nervous system (ANS) regulation, increasing the risk for secondary complications, hemodynamic instability, and adverse outcome. This retrospective study evaluated windowed time-lagged cross-correlation (WTLCC) matrices for describing cerebral hemodynamics-ANS interactions to predict outcome, enabling identifying high-risk patients who may benefit from enhanced monitoring to prevent complications. METHODS The first experiment aimed to predict short-term outcome using WTLCC-based convolution neural network models on the Wroclaw University Hospital (WUH) database (Ptraining = 31 with 1,079 matrices, Pval = 16 with 573 matrices). The second experiment predicted long-term outcome, training on the CENTER-TBI database (Ptraining = 100 with 17,062 matrices) and validating on WUH (Pval = 47 with 6,220 matrices). Cerebral hemodynamics was characterized using intracranial pressure (ICP), cerebral perfusion pressure (CPP), pressure reactivity index (PRx), while ANS metrics included low-to-high-frequency heart rate variability (LF/HF) and baroreflex sensitivity (BRS) over 72 h. Short-term outcome at WUH was assessed using the Glasgow Outcome Scale (GOS) at discharge. Long-term outcome was evaluated at 3 months at WUH and 6 months at CENTER-TBI using GOS and GOS-Extended, respectively. The XGBoost model was used to compare performance of WTLCC-based model and averaged neuromonitoring parameters, adjusted for age, Glasgow Coma Scale, major extracranial injury, and pupil reactivity in outcome prediction. RESULTS For short-term outcome prediction, the best-performing WTLCC-based model used ICP-LF/HF matrices. It had an area under the curve (AUC) of 0.80, vs. 0.71 for averages of ANS and cerebral hemodynamics metrics, adjusted for clinical metadata. For long-term outcome prediction, the best-score WTLCC-based model used ICP-LF/HF matrices. It had an AUC of 0.63, vs. 0.66 for adjusted neuromonitoring parameters. CONCLUSIONS Among all neuromonitoring parameters, ICP and LF/HF signals were the most effective in generating the WTLCC matrices. WTLCC-based model outperformed adjusted neuromonitoring parameters in short-term but had moderate utility in long-term outcome prediction.
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Affiliation(s)
- Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland.
| | - Cyprian Mataczyński
- Department of Computer Engineering, Faculty of Information and Communication Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Adam I Pelah
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke Hospital, University of Cambridge, Cambridge, UK
| | - Małgorzata Burzyńska
- Clinical Department of Anesthesiology and Intensive Care, Faculty of Medicine, Wroclaw Medical University, Wroclaw, Poland
| | - Chiara Robba
- IRCCS Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Viale Benedetto XV 16, Genoa, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke Hospital, University of Cambridge, Cambridge, UK
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Choudhury A, Ravikant, Bairwa M, Jithesh G, Kumar S, Kumar N. Efficacy of Intravenous 20% Mannitol vs 3% Hypertonic Saline in Reducing Intracranial Pressure in Nontraumatic Brain Injury: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2024; 28:686-695. [PMID: 38994261 PMCID: PMC11234117 DOI: 10.5005/jp-journals-10071-24746] [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: 12/19/2023] [Accepted: 05/27/2024] [Indexed: 07/13/2024] Open
Abstract
Background Nontraumatic brain injury encompasses various pathological processes and medical conditions that result in brain dysfunction and neurological impairment without direct physical trauma. The study aimed to assess the efficacy of intravenous administration of 20% mannitol and 3% hypertonic saline to reduce intracranial pressure in nontraumatic brain injury. Materials and methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were followed for study selection and data extraction. The search was conducted in the PubMed, Embase, and Scopus databases, including articles published in English from January 2003 to December 2023. Our study included randomized controlled trials, comparative studies, prospective analyses, and retrospective cohort studies. We extracted data on baseline characteristics of patients, intervention details, major outcomes, and complications. Quality assessment was performed using the Jadad scale and the Robvis assessment tool for risk of bias. Results A total of 14 studies involving 1,536 patients were included in the analysis. Seven studies reported hypertonic saline as more effective in reducing intracranial pressure, while three studies found similar effectiveness for both interventions. Adverse events were reported in only three studies. The studies that reported complication rates ranged from 21 to 79%. A meta-analysis was conducted on five studies, showing varying rates of adverse events associated with mannitol and hypertonic saline. Conclusion Both hypertonic saline solution and mannitol have been explored as treatment options for decreasing intracranial pressure in nontraumatic brain injuries. While some studies indicate the superiority of hypertonic saline, others report similar effectiveness between the two interventions. How to cite this article Choudhury A, Ravikant, Bairwa M, Jithesh G, Kumar S, Kumar N. Efficacy of Intravenous 20% Mannitol vs 3% Hypertonic Saline in Reducing Intracranial Pressure in Nontraumatic Brain Injury: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2024;28(7):686-695.
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Affiliation(s)
| | - Ravikant
- Department of Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Mukesh Bairwa
- Department of Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - G Jithesh
- Department of Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Sahil Kumar
- Department of Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nitin Kumar
- Department of Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
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Gaither JB, Spaite DW, Bobrow BJ, Barnhart B, Chikani V, Denninghoff KR, Bradley GH, Rice AD, Howard JT, Keim SM, Hu C. EMS Treatment Guidelines in Major Traumatic Brain Injury With Positive Pressure Ventilation. JAMA Surg 2024; 159:363-372. [PMID: 38265782 PMCID: PMC10809136 DOI: 10.1001/jamasurg.2023.7155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 09/13/2023] [Indexed: 01/25/2024]
Abstract
Importance The Excellence in Prehospital Injury Care (EPIC) study demonstrated improved survival in patients with severe traumatic brain injury (TBI) following implementation of the prehospital treatment guidelines. The impact of implementing these guidelines in the subgroup of patients who received positive pressure ventilation (PPV) is unknown. Objective To evaluate the association of implementation of prehospital TBI evidence-based guidelines with survival among patients with prehospital PPV. Design, Setting, and Participants The EPIC study was a multisystem, intention-to-treat study using a before/after controlled design. Evidence-based guidelines were implemented by emergency medical service agencies across Arizona. This subanalysis was planned a priori and included participants who received prehospital PPV. Outcomes were compared between the preimplementation and postimplementation cohorts using logistic regression, stratified by predetermined TBI severity categories (moderate, severe, or critical). Data were collected from January 2007 to June 2017, and data were analyzed from January to February 2023. Exposure Implementation of the evidence-based guidelines for the prehospital care of patient with TBI. Main Outcomes and Measures The primary outcome was survival to hospital discharge, and the secondary outcome was survival to admission. Results Among the 21 852 participants in the main study, 5022 received prehospital PPV (preimplementation, 3531 participants; postimplementation, 1491 participants). Of 5022 included participants, 3720 (74.1%) were male, and the median (IQR) age was 36 (22-54) years. Across all severities combined, survival to admission improved (adjusted odds ratio [aOR], 1.59; 95% CI, 1.28-1.97), while survival to discharge did not (aOR, 0.94; 95% CI, 0.78-1.13). Within the cohort with severe TBI but not in the moderate or critical subgroups, survival to hospital admission increased (aOR, 6.44; 95% CI, 2.39-22.00), as did survival to discharge (aOR, 3.52; 95% CI, 1.96-6.34). Conclusions and Relevance Among patients with severe TBI who received active airway interventions in the field, guideline implementation was independently associated with improved survival to hospital admission and discharge. This was true whether they received basic airway interventions or advanced airways. These findings support the current guideline recommendations for aggressive prevention/correction of hypoxia and hyperventilation in patients with severe TBI, regardless of which airway type is used.
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Affiliation(s)
- Joshua B. Gaither
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Daniel W. Spaite
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Bentley J. Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, Texas
| | - Bruce Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
| | - Vatsal Chikani
- Department of Public Health, University of Texas at San Antonio
| | - Kurt R. Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Gail H. Bradley
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
- Arizona Department of Health Services, Bureau of EMS, Phoenix
| | - Amber D. Rice
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | | | - Samuel M. Keim
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Department of Emergency Medicine, College of Medicine, The University of Arizona, Tucson
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine—Phoenix, The University of Arizona, Phoenix
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson
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Quintana-Diaz M, Anania P, Juárez-Vela R, Echaniz-Serrano E, Tejada-Garrido CI, Sanchez-Conde P, Nanwani-Nanwani K, Serrano-Lázaro A, Marcos-Neira P, Gero-Escapa M, García-Criado J, Godoy DA. "COAGULATION": a mnemonic device for treating coagulation disorders following traumatic brain injury-a narrative-based method in the intensive care unit. Front Public Health 2023; 11:1309094. [PMID: 38125841 PMCID: PMC10730733 DOI: 10.3389/fpubh.2023.1309094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Accepted: 11/21/2023] [Indexed: 12/23/2023] Open
Abstract
Introduction Coagulopathy associated with isolated traumatic brain injury (C-iTBI) is a frequent complication associated with poor outcomes, primarily due to its role in the development or progression of haemorrhagic brain lesions. The independent risk factors for its onset are age, severity of traumatic brain injury (TBI), volume of fluids administered during resuscitation, and pre-injury use of antithrombotic drugs. Although the pathophysiology of C-iTBI has not been fully elucidated, two distinct stages have been identified: an initial hypocoagulable phase that begins within the first 24 h, dominated by platelet dysfunction and hyperfibrinolysis, followed by a hypercoagulable state that generally starts 72 h after the trauma. The aim of this study was to design an acronym as a mnemonic device to provide clinicians with an auxiliary tool in the treatment of this complication. Methods A narrative analysis was performed in which intensive care physicians were asked to list the key factors related to C-iTBI. The initial sample was comprised of 33 respondents. Respondents who were not physicians, not currently working in or with experience in coagulopathy were excluded. Interviews were conducted for a month until the sample was saturated. Each participant was asked a single question: Can you identify a factor associated with coagulopathy in patients with TBI? Factors identified by respondents were then submitted to a quality check based on published studies and proven evidence. Because all the factors identified had strong support in the literature, none was eliminated. An acronym was then developed to create the mnemonic device. Results and conclusion Eleven factors were identified: cerebral computed tomography, oral anticoagulant & antiplatelet use, arterial blood pressure (Hypotension), goal-directed haemostatic therapy, use fluids cautiously, low calcium levels, anaemia-transfusion, temperature, international normalised ratio (INR), oral antithrombotic reversal, normal acid-base status, forming the acronym "Coagulation." This acronym is a simple mnemonic device, easy to apply for anyone facing the challenge of treating patients of moderate or severe TBI on a daily basis.
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Affiliation(s)
- Manuel Quintana-Diaz
- Department of Medicine, Faculty of Medicine, Autonomous University of Madrid, Madrid, Spain
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
| | - Pasquale Anania
- Department of Neurosurgery, Ospedale Policlinico San Martino, Istituto di Ricovero eCura a Carattere Scientifico (IRCCS) for Oncology and Neuroscience, Genoa, Italy
| | - Raúl Juárez-Vela
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
- Department of Nursing, University of La Rioja, Logroño, Spain
- Health and Healthcare Research Group (GRUPAC), Faculty of Health Sciences, University of La Rioja, Logroño, Spain
| | - Emmanuel Echaniz-Serrano
- Department of Nursing and Physiatry, Faculty of Health Sciences, University of Zaragoza, Zaragoza, Spain
- Aragon Healthcare Service, Aragon, Zaragoza, Spain
| | - Clara Isabel Tejada-Garrido
- Department of Nursing, University of La Rioja, Logroño, Spain
- Health and Healthcare Research Group (GRUPAC), Faculty of Health Sciences, University of La Rioja, Logroño, Spain
| | | | - Kapil Nanwani-Nanwani
- Intensive Care Unit, La Paz University Hospital, Madrid, Spain
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
| | - Ainhoa Serrano-Lázaro
- Institute for Health Research (idiPAZ), La Paz University Hospital, Madrid, Spain
- Intensive Care Unit, Valencia University Clinical Hospital, Valencia, Spain
| | - Pilar Marcos-Neira
- Intensive Care Unit, Germans Trias i Pujol University Hospital, Badalona, Spain
| | | | | | - Daniel Agustín Godoy
- Critical Care Department, Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina
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Pastor IS, Para I, Vesa ȘC, Florian IȘ. Identifying predictive factors for mortality in patients with TBI at a neurosurgery department. J Med Life 2023; 16:554-558. [PMID: 37305827 PMCID: PMC10251389 DOI: 10.25122/jml-2023-0114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/11/2023] [Indexed: 06/13/2023] Open
Abstract
Traumatic brain injury (TBI) can have severe consequences in most cases. Many therapeutic and neurosurgical strategies have been improved to optimize patient outcomes. However, despite adequate surgery and intensive care, death can still occur during hospitalization. TBI often results in protracted hospital stays in neurosurgery departments, indicating the severity of brain injury. Several factors related to TBI are predictive of longer hospital stays and in-hospital mortality rates. This study aimed to identify predictive factors for intrahospital days of death due to TBI. This was a longitudinal, retrospective, analytical, observational study that included 70 TBI-related deaths admitted to the Neurosurgery Clinic in Cluj-Napoca for a period of four years (January 2017 to December 2021) using a cohort model. We identified some clinical data related to intrahospital death after TBI. The severity of TBI was classified as mild (n=9), moderate(n=13), and severe (n=48) and was associated with significantly fewer hospital days (p=0.009). Patients with associated trauma, such as vertebro-medullary or thoracic trauma, were more likely to die after a few days of hospitalization (p=0.007). Surgery applied in TBI was associated with a higher median number of days until death compared to conservative treatment. A low GCS was an independent predictive factor for early intrahospital mortality in patients with TBI. In conclusion, clinical factors such as the severity of injury, low GCS, and polytrauma are predictive of early intrahospital mortality. Surgery was associated with prolonged hospitalization.
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Affiliation(s)
- Iulia-Sevastiana Pastor
- Department of Neurosurgery, Faculty of Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioana Para
- 4 Department of Internal Medicine, Faculty of Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ștefan Cristian Vesa
- Pharmacology, Toxicology and Clinical Pharmacology, Faculty of Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioan Ștefan Florian
- Department of Neurosurgery, Faculty of Medicine, Iuliu Hațieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
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11
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Widdop L, Kaukas L, Wells A. Effect of Pre-Management Antithrombotic Agent Use on Outcome after Traumatic Acute Subdural Hematoma in the Elderly: A Systematic Review. J Neurotrauma 2023; 40:635-648. [PMID: 36266996 DOI: 10.1089/neu.2022.0052] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Traumatic acute subdural hematomas (ASDH) are common in elderly patients (age ≥65 years) and are associated with a poorer prognosis compared with younger populations. Antithrombotic agent (ATA) use is also common in the elderly; however, the influence that pre-morbid ATA has on outcome in ASDH is poorly understood. We hypothesized that pre-morbid ATA use significantly worsens outcomes in elderly patients presenting with traumatic ASDH. English language medical literature was searched for articles relating to ATA use in the elderly with ASDH. Data were collated and appraised where possible. Analyses of study bias were performed. Twelve articles encompassing 2038 patients were included; controls were poorly described in the included studies. Pre-morbid ATA use was seen in 1042 (51.1%) patients and 18 different ATA combination therapies were identified, with coumarins being the most common single agent used. The newer direct oral anticoagulants were evaluated in only two studies. ATA use was associated with a lower presenting Glasgow Coma Scale (GCS) score but not hematoma volume on computed tomography (CT) or post-operative hematoma re-accumulation. No studies connected ATA use with patient outcomes without the presence of confounders and bias. Reversal strategies, bridging therapy, recommencement of ATA, and comparison groups were poorly described; accordingly, our hypothesis was rejected. ATA reversal methods, identification of surgical candidates, optimal surgery methods, and when or whether ATA should be recommenced following ASDH resolution remain topics of debate. This study defines our current understanding on this topic, revealing clear deficiencies in the literature with recommendations for future research.
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Affiliation(s)
- Liam Widdop
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lola Kaukas
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adam Wells
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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12
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Second- and Third-Tier Therapies for Severe Traumatic Brain Injury. J Clin Med 2022; 11:jcm11164790. [PMID: 36013029 PMCID: PMC9410180 DOI: 10.3390/jcm11164790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/13/2022] [Accepted: 08/15/2022] [Indexed: 12/04/2022] Open
Abstract
Intracranial hypertension is a common finding in patients with severe traumatic brain injury. These patients need treatment in the intensive care unit, where intracranial pressure monitoring and, whenever possible, multimodal neuromonitoring can be applied. A three-tier approach is suggested in current recommendations, in which higher-tier therapies have more significant side effects. In this review, we explain the rationale for this approach, and analyze the benefits and risks of each therapeutic modality. Finally, we discuss, based on the most recent recommendations, how this approach can be adapted in low- and middle-income countries, where available resources are limited.
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13
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Acharya D, Mukherjea A, Cao J, Ruesch A, Schmitt S, Yang J, Smith MA, Kainerstorfer JM. Non-Invasive Spectroscopy for Measuring Cerebral Tissue Oxygenation and Metabolism as a Function of Cerebral Perfusion Pressure. Metabolites 2022; 12:metabo12070667. [PMID: 35888791 PMCID: PMC9323243 DOI: 10.3390/metabo12070667] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) and diffuse correlation spectroscopy (DCS) measure cerebral hemodynamics, which in turn can be used to assess the cerebral metabolic rate of oxygen (CMRO2) and cerebral autoregulation (CA). However, current mathematical models for CMRO2 estimation make assumptions that break down for cerebral perfusion pressure (CPP)-induced changes in CA. Here, we performed preclinical experiments with controlled changes in CPP while simultaneously measuring NIRS and DCS at rest. We observed changes in arterial oxygen saturation (~10%) and arterial blood volume (~50%) with CPP, two variables often assumed to be constant in CMRO2 estimations. Hence, we propose a general mathematical model that accounts for these variations when estimating CMRO2 and validate its use for CA monitoring on our experimental data. We observed significant changes in the various oxygenation parameters, including the coupling ratio (CMRO2/blood flow) between regions of autoregulation and dysregulation. Our work provides an appropriate model and preliminary experimental evidence for the use of NIRS- and DCS-based tissue oxygenation and metabolism metrics for non-invasive diagnosis of CA health in CPP-altering neuropathologies.
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Affiliation(s)
- Deepshikha Acharya
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Ankita Mukherjea
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Jiaming Cao
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Alexander Ruesch
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Samantha Schmitt
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Jason Yang
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Matthew A. Smith
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Jana M. Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
- Correspondence:
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14
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Dynamic prediction of mortality after traumatic brain injury using a machine learning algorithm. NPJ Digit Med 2022; 5:96. [PMID: 35851612 PMCID: PMC9293936 DOI: 10.1038/s41746-022-00652-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 07/06/2022] [Indexed: 11/08/2022] Open
Abstract
Intensive care for patients with traumatic brain injury (TBI) aims to optimize intracranial pressure (ICP) and cerebral perfusion pressure (CPP). The transformation of ICP and CPP time-series data into a dynamic prediction model could aid clinicians to make more data-driven treatment decisions. We retrained and externally validated a machine learning model to dynamically predict the risk of mortality in patients with TBI. Retraining was done in 686 patients with 62,000 h of data and validation was done in two international cohorts including 638 patients with 60,000 h of data. The area under the receiver operating characteristic curve increased with time to 0.79 and 0.73 and the precision recall curve increased with time to 0.57 and 0.64 in the Swedish and American validation cohorts, respectively. The rate of false positives decreased to ≤2.5%. The algorithm provides dynamic mortality predictions during intensive care that improved with increasing data and may have a role as a clinical decision support tool.
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15
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The Impact of Hyperoxia Treatment on Neurological Outcomes and Mortality in Moderate to Severe Traumatic Brain Injured Patients. J Crit Care Med (Targu Mures) 2021; 7:227-236. [PMID: 34722926 PMCID: PMC8519380 DOI: 10.2478/jccm-2021-0014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 05/03/2021] [Indexed: 12/04/2022] Open
Abstract
Background Traumatic brain injury is a leading cause of morbidity and mortality worldwide. The relationship between hyperoxia and outcomes in patients with TBI remains controversial. We assessed the effect of persistent hyperoxia on the neurological outcomes and survival of critically ill patients with moderate-severe TBI. Method This was a retrospective cohort study of all adults with moderate-severe TBI admitted to the ICU between 1st January 2016 and 31st December 2019 and who required invasive mechanical ventilation. Arterial blood gas data was recorded within the first 3 hours of intubation and then after 6-12 hours and 24-48 hours. The patients were divided into two categories: Group I had a PaO2 < 120mmHg on at least two ABGs undertaken in the first twelve hours post intubation and Group II had a PaO2 ≥ 120mmHg on at least two ABGs in the same period. Multivariable logistic regression was performed to assess predictors of hospital mortality and good neurologic outcome (Glasgow outcome score ≥ 4). Results The study included 309 patients: 54.7% (n=169) in Group I and 45.3% (n=140) in Group II. Hyperoxia was not associated with increased mortality in the ICU (20.1% vs. 17.9%, p=0.62) or hospital (20.7% vs. 17.9%, p=0.53), moreover, the hospital discharge mean (SD) Glasgow Coma Scale (11.0(5.1) vs. 11.2(4.9), p=0.70) and mean (SD) Glasgow Outcome Score (3.1(1.3) vs. 3.1(1.2), p=0.47) were similar. In multivariable logistic regression analysis, persistent hyperoxia was not associated with increased mortality (adjusted odds ratio [aOR] 0.71, 95% CI 0.34-1.35, p=0.29). PaO2 within the first 3 hours was also not associated with mortality: 121-200mmHg: aOR 0.58, 95% CI 0.23-1.49, p=0.26; 201-300mmHg: aOR 0.66, 95% CI 0.27-1.59, p=0.35; 301-400mmHg: aOR 0.85, 95% CI 0.31-2.35, p=0.75 and >400mmHg: aOR 0.51, 95% CI 0.18-1.44, p=0.20; reference: PaO2 60-120mmHg within 3 hours. However, hyperoxia >400mmHg was associated with being less likely to have good neurological (GOS ≥4) outcome on hospital discharge (aOR 0.36, 95% CI 0.13-0.98, p=0.046; reference: PaO2 60-120mmHg within 3 hours. Conclusion In intubated patients with moderate-severe TBI, hyperoxia in the first 48 hours was not independently associated with hospital mortality. However, PaO2 >400mmHg may be associated with a worse neurological outcome on hospital discharge.
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16
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Marini CP, McNelis J, Petrone P. Multimodality Monitoring and Goal-Directed Therapy for the Treatment of Patients with Severe Traumatic Brain Injury: A Review for the General and Trauma Surgeon. Curr Probl Surg 2021; 59:101070. [DOI: 10.1016/j.cpsurg.2021.101070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
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Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, Ponsford J, Seppelt I, Reilly P, Wiegers E, Wolfe R. Patient Outcomes at Twelve Months after Early Decompressive Craniectomy for Diffuse Traumatic Brain Injury in the Randomized DECRA Clinical Trial. J Neurotrauma 2021; 37:810-816. [PMID: 32027212 PMCID: PMC7071071 DOI: 10.1089/neu.2019.6869] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients. We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. At 12 months, the odds ratio (OR) for worse functional outcomes in the craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes. Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased. Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive craniectomy did not improve outcomes and increased vegetative survivors.
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Affiliation(s)
- D James Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Lynnette Murray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yaseen M Arabi
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Andrew R Davies
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia.,Monash-Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Peter Reilly
- Neurosurgery Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eveline Wiegers
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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18
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Clinical features and treatment strategies for vertex epidural hematoma: a systematic review and meta-analysis from individual participant data. Neurosurg Rev 2021; 45:819-830. [PMID: 34313885 DOI: 10.1007/s10143-021-01589-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 10/20/2022]
Abstract
Vertex epidural hematoma (VEDH) is a rare extradural hematoma and often misdiagnosed because of its variety of clinical symptoms and characteristic location. Determining optimal timing and technique for VEDH surgery is difficult because of its midline location and atypical clinical course. This study aims to understand the clinical manifestations and current treatment strategies for VEDH. We searched the published literature regarding VEDH through PubMed and Google Scholar, and individual patient data (IPD) were obtained from the eligible articles. A systematic review and IPD meta-analysis were conducted. In total, 70 patients' individual participant data were gathered. Most patients were male (87%), and traffic-related accidents were the most common injury mechanism (49%). Approximately half the patients (47%) were neurologically intact with nonspecific symptoms such as headache, dizziness, and vomiting at admission. Motor weakness alone (17%) and symptoms related to cranial nerve dysfunction such as anosmia, blurred vision, or diplopia (10%) were also noted. A surgical approach was initially chosen for 20 patients (28%), but eventually chosen for 20 more (total 40, 57%) during the observation period (average delay to surgery, 5 days). Patients who received surgery showed significantly poorer neurological status and larger hematoma size. Totally, two patients (3%) died, but most patients (94%) had a favorable outcome scoring 5 on the Glasgow Outcome Scale. Although VEDH generally showed favorable outcomes, clinicians must be aware of a high rate of delayed neurological deterioration during the observation period, which can be fatal due to central downward herniation.
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19
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Mataczynski C, Kazimierska A, Uryga A, Burzynska M, Rusiecki A, Kasprowicz M. End-to-End Automatic Morphological Classification of Intracranial Pressure Pulse Waveforms Using Deep Learning. IEEE J Biomed Health Inform 2021; 26:494-504. [PMID: 34115601 DOI: 10.1109/jbhi.2021.3088629] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Mean intracranial pressure (ICP) is commonly used in the management of patients with intracranial pathologies. However, the shape of the ICP signal over a single cardiac cycle, called ICP pulse waveform, also contains information on the state of the craniospinal space. In this study we aimed to propose an end-to-end approach to classification of ICP waveforms and assess its potential clinical applicability. METHODS ICP pulse waveforms obtained from long-term ICP recordings of 50 neurointensive care unit (NICU) patients were manually classified into four classes ranging from normal to pathological. An additional class was introduced to simultaneously identify artifacts. Several deep learning models and data representations were evaluated. An independent testing dataset was used to assess the performance of final models. Occurrence of different waveform types was compared with the patients clinical outcome. RESULTS Residual Neural Network using 1-D ICP signal as input was identified as the best performing model with accuracy of 93\% in the validation and 82\% in the testing dataset. Patients with unfavorable outcome exhibited significantly lower incidence of normal waveforms compared to the favorable outcome group at ICP levels below 20 mm Hg (median [first-third quartile]: 6 [1-37] \% vs. 56 [12-71] \%, p=0.005). CONCLUSIONS Results of this study confirm the possibility of analyzing ICP pulse waveform morphology in long-term recordings of NICU patients. Proposed approach could potentially be used to provide additional information on the state of patients with intracranial pathologies beyond mean ICP.
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20
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Kang J, Song YJ, Jeon S, Lee J, Lee E, Lee JY, Lee E, Bang JS, Lee SU, Han MK, Oh CW, Kim T. Intravenous Fluid Selection for Unruptured Intracranial Aneurysm Clipping : Balanced Crystalloid versus Normal Saline. J Korean Neurosurg Soc 2021; 64:534-542. [PMID: 34044495 PMCID: PMC8273783 DOI: 10.3340/jkns.2020.0262] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 10/20/2020] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE While balanced crystalloid (BC) could be a relevant fluid regimen with buffer system compared with normal saline (NS), there have been no studies on the optimal fluid for surgery of an unruptured intracranial aneurysm (UIA). This study aimed to compare the effects of fluid regimens between NS and BC on the metabolic and clinical outcomes of patients who underwent surgery for UIA. METHODS This study was designed as a propensity score matched retrospective comparative study and included adult patients who underwent UIA clipping. Patient groups were categorized as NS and BC groups based on the types of pre-operative fluid and the amount of fluid administered during surgery. The primary outcomes were defined as electrolyte imbalance and acidosis immediately after surgery. The secondary outcomes were the length of stay in the intensive care unit (ICU) and duration from the end of the operation to extubation. RESULTS A total of 586 patients were enrolled in this study, with each of 293 patients assigned to the NS and BC groups, respectively. Immediately after surgery, serum chloride levels were significantly higher in the NS group. Compared to the NS group, the BC group had lower incidence rates of acidemia (6.5% vs. 11.6%, p=0.043) and metabolic acidosis (0.7% vs. 4.4%, p=0.007). As compared to NS group, BC group had significantly shorter duration from the end of the operation to extubation (250±824 vs. 122±372 minutes, p=0.016) and length of stay in ICU (1.37±1.11 vs. 1.12±0.61 days, p=0.001). Throughout multivariable analysis, use of BC was found to be significant factor for favorable post-operative results. CONCLUSION This study showed that the patients who received BC during UIA clipping had lower incidence of metabolic acidosis, earlier extubation and shorter ICU stay compared to those who received NS. Therefore, using BC as a peri-operative fluid can be recommended for patients who undergo surgery for UIA.
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Affiliation(s)
- Jian Kang
- Department of Pharmacy, Seoul National University Bundang Hospital, Seoungnam, Korea
| | - Young Joo Song
- Department of Pharmacy, Seoul National University Bundang Hospital, Seoungnam, Korea
| | - Sujeong Jeon
- Department of Pharmacy, Seoul National University Bundang Hospital, Seoungnam, Korea
| | - Junghwa Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seoungnam, Korea
| | - Eunsook Lee
- Department of Pharmacy, Seoul National University Bundang Hospital, Seoungnam, Korea
| | - Ju-Yeun Lee
- College of Pharmacy & Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Korea
| | - Euni Lee
- College of Pharmacy & Research Institute of Pharmaceutical Sciences, Seoul National University, Seoul, Korea
| | - Jae Seung Bang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Si Un Lee
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Moon-Ku Han
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tackeun Kim
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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21
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Riberholt CG, Olsen MH, Søndergaard CB, Gluud C, Ovesen C, Jakobsen JC, Mehlsen J, Møller K. Early Orthostatic Exercise by Head-Up Tilt With Stepping vs. Standard Care After Severe Traumatic Brain Injury Is Feasible. Front Neurol 2021; 12:626014. [PMID: 33935935 PMCID: PMC8079637 DOI: 10.3389/fneur.2021.626014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 03/22/2021] [Indexed: 12/01/2022] Open
Abstract
Background: Intensive rehabilitation of patients after severe traumatic brain injury aims to improve functional outcome. The effect of initiating rehabilitation in the early phase, in the form of head-up mobilization, is unclear. Objective: To assess whether early mobilization is feasible and safe in patients with traumatic brain injury admitted to a neurointensive care unit. Methods: This was a randomized parallel-group clinical trial, including patients with severe traumatic brain injury (Glasgow coma scale <11 and admission to the neurointensive care unit). The intervention consisted of daily mobilization on a tilt-table for 4 weeks. The control group received standard care. Outcomes were the number of included participants relative to all patients with traumatic brain injury who were approached for inclusion, the number of conducted mobilization sessions relative to all planned sessions, as well as adverse events and reactions. Information on clinical outcome was collected for exploratory purposes. Results: Thirty-eight participants were included (19 in each group), corresponding to 76% of all approached patients [95% confidence interval (CI) 63–86%]. In the intervention group, 74% [95% CI 52–89%] of planned sessions were carried out. There was no difference in the number of adverse events, serious adverse events, or adverse reactions between the groups. Conclusions: Early head-up mobilization is feasible in patients with severe traumatic brain injury. Larger randomized clinical trials are needed to explore potential benefits and harms of such an intervention. Clinical Trial Registration: [ClinicalTrials.gov], identifier [NCT02924649]. Registered on 3rd October 2016.
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Affiliation(s)
- Christian Gunge Riberholt
- Traumatic Brain Injury Unit, Department of Neurorehabilitation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neuroanaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | | | - Christian Gluud
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Christian Ovesen
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Neurology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Department 7812, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Jesper Mehlsen
- Surgical Pathophysiology Unit, Juliane Marie Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Neuroanaesthesiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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22
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Salottolo K, Panchal R, Madayag RM, Dhakal L, Rosenberg W, Banton KL, Hamilton D, Bar-Or D. Incorporating age improves the Glasgow Coma Scale score for predicting mortality from traumatic brain injury. Trauma Surg Acute Care Open 2021; 6:e000641. [PMID: 33634212 PMCID: PMC7880096 DOI: 10.1136/tsaco-2020-000641] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 01/05/2021] [Accepted: 01/29/2021] [Indexed: 12/19/2022] Open
Abstract
Background The Glasgow Coma Scale (GCS) score has been adapted into categories of severity (mild, moderate, and severe) and are ubiquitous in the trauma setting. This study sought to revise the GCS categories to account for an interaction by age and to determine the discrimination of the revised categories compared with the standard GCS categories. Methods The American College of Surgeons National Trauma Data Bank registry was used to identify patients with traumatic brain injury (TBI; ICD-9 codes 850-854.19) who were admitted to participating trauma centers from 2010 to 2015. The primary exposure variables were GCS score and age, categorized by decade (teens, 20s, 30s…, 80s). In-hospital mortality was the primary outcome for examining TBI severity/prognostication. Logistic regression was used to calculate the conditional probability of death by age decade and GCS in a development dataset (75% of patients). These probabilities were used to create a points-based revision of the GCS, categorized as low (mild), moderate, and high (severe). Performance of the revised versus standard GCS categories was compared in the validation dataset using area under the receiver operating characteristic (AUC) curves. Results The final population included 539,032 patients with TBI. Age modified the performance of the GCS, resulting in a novel categorization schema for each age decile. For patients in their 50s, performance of the revised GCS categories mirrored the standard GCS categorization (3-8, 9-12, 13-15); all other revised GCS categories were heavily modified by age. Model validation demonstrated the revised GCS categories statistically significantly outperformed the standard GCS categories at predicting mortality (AUC: 0.800 vs 0.755, p<0.001). The revised GCS categorization also outperformed the standard GCS categories for mortality within pre-specified subpopulations: blunt mechanism, isolated TBI, falls, non-transferred patients. Discussion We propose the revised age-adjusted GCS categories will improve severity assessment and provide a more uniform early prognostic indicator of mortality following traumatic brain injury. Level of evidence III epidemiologic/prognostic.
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Affiliation(s)
| | - Ripul Panchal
- Neurosurgery, Medical Center of Plano, Plano, Texas, USA
| | - Robert M Madayag
- Trauma Services Department, St Anthony Hospital and Medical Campus, Lakewood, Colorado, USA
| | - Laxmi Dhakal
- Neurosurgery, Wesley Medical Center, Wichita, Kansas, USA
| | | | - Kaysie L Banton
- Trauma Services Department, Swedish Medical Center, Englewood, Colorado, USA
| | - David Hamilton
- Trauma Services Department, Penrose Hospital, Colorado Springs, Colorado, USA
| | - David Bar-Or
- Trauma Research, Swedish Medical Center, Englewood, Colorado, USA
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23
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Huijben JA, Dixit A, Stocchetti N, Maas AIR, Lingsma HF, van der Jagt M, Nelson D, Citerio G, Wilson L, Menon DK, Ercole A. Use and impact of high intensity treatments in patients with traumatic brain injury across Europe: a CENTER-TBI analysis. Crit Care 2021; 25:78. [PMID: 33622371 PMCID: PMC7901510 DOI: 10.1186/s13054-020-03370-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/03/2020] [Indexed: 01/09/2023] Open
Abstract
PURPOSE To study variation in, and clinical impact of high Therapy Intensity Level (TIL) treatments for elevated intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across European Intensive Care Units (ICUs). METHODS We studied high TIL treatments (metabolic suppression, hypothermia (< 35 °C), intensive hyperventilation (PaCO2 < 4 kPa), and secondary decompressive craniectomy) in patients receiving ICP monitoring in the ICU stratum of the CENTER-TBI study. A random effect logistic regression model was used to determine between-centre variation in their use. A propensity score-matched model was used to study the impact on outcome (6-months Glasgow Outcome Score-extended (GOSE)), whilst adjusting for case-mix severity, signs of brain herniation on imaging, and ICP. RESULTS 313 of 758 patients from 52 European centres (41%) received at least one high TIL treatment with significant variation between centres (median odds ratio = 2.26). Patients often transiently received high TIL therapies without escalation from lower tier treatments. 38% of patients with high TIL treatment had favourable outcomes (GOSE ≥ 5). The use of high TIL treatment was not significantly associated with worse outcome (285 matched pairs, OR 1.4, 95% CI [1.0-2.0]). However, a sensitivity analysis excluding high TIL treatments at day 1 or use of metabolic suppression at any day did reveal a statistically significant association with worse outcome. CONCLUSION Substantial between-centre variation in use of high TIL treatments for TBI was found and treatment escalation to higher TIL treatments were often not preceded by more conventional lower TIL treatments. The significant association between high TIL treatments after day 1 and worse outcomes may reflect aggressive use or unmeasured confounders or inappropriate escalation strategies. TAKE HOME MESSAGE Substantial variation was found in the use of highly intensive ICP-lowering treatments across European ICUs and a stepwise escalation strategy from lower to higher intensity level therapy is often lacking. Further research is necessary to study the impact of high therapy intensity treatments. TRIAL REGISTRATION The core study was registered with ClinicalTrials.gov, number NCT02210221, registered 08/06/2014, https://clinicaltrials.gov/ct2/show/NCT02210221?id=NCT02210221&draw=1&rank=1 and with Resource Identification Portal (RRID: SCR_015582).
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Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Abhishek Dixit
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
- Fondazione IRCCS Ca'Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Hester F Lingsma
- Center for Medical Decision Sciences, Department of Public Health, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC- University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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24
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Hui J, Feng J, Tu Y, Zhang W, Zhong C, Liu M, Wang Y, Long L, Chen L, Liu J, Mou C, Qiu B, Huang X, Huang Q, Zhang N, Yang X, Yang C, Li L, Ma R, Wu X, Lei J, Jiang Y, Liu L, Gao G, Jiang J, the LTH-1 Trial collaborators. Safety and efficacy of long-term mild hypothermia for severe traumatic brain injury with refractory intracranial hypertension (LTH-1): A multicenter randomized controlled trial. EClinicalMedicine 2021; 32:100732. [PMID: 33681741 PMCID: PMC7910713 DOI: 10.1016/j.eclinm.2021.100732] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/13/2021] [Accepted: 01/14/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Therapeutic hypothermia may need prolonged duration for the patients with severe traumatic brain injury (sTBI). METHODS The Long-Term Hypothermia trial was a prospective, multicenter, randomized, controlled clinical trial to examine the safety and efficacy in adults with sTBI. Eligible patients were 18-65, Glasgow Coma Scale score at 4 to 8, and initial intracranial pressure (ICP) ≥ 25 mm Hg, randomly assigned to the long-term mild hypothermia group (34-35 °C for 5 days) or normothermia group at 37 °C. The primary outcome was the Glasgow outcome scale (GOS) at 6 months. Secondary outcomes included ICP control, complications and laboratory findings, the length of ICU and hospital stay, and GOS at 6 months in patients with initial ICP ≥ 30 mm Hg. This trial is registered with ClinicalTrials.gov, NCT01886222. FINDINGS 302 patients were enrolled from June 25, 2013, to December 31, 2018, with 6 months follow-up in 14 hospitals, 156 in hypothermia group and 146 in normothermia group. There was no difference in favorable outcome (OR 1·55, 95%CI 0·91-2·64; P = 0·105) and in mortality (P = 0·111) between groups. In patients with an initial ICP ≥ 30 mm Hg, hypothermic treatment significantly increased favorable outcome over normothermia group (60·82%, 42·71%, respectively; OR 1·861, 95%CI 1·031-3·361; P = 0·039). Long-term mild hypothermia did not increase the incidences of complications. INTERPRETATION Long-term mild hypothermia did not improve the neurological outcomes. However, it may be a potential option in sTBI patients with initial ICP ≥ 30 mm Hg. FUNDING : Shanghai municipal government and Shanghai Jiao Tong University/School of Medicine.
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Affiliation(s)
- Jiyuan Hui
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Junfeng Feng
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Yue Tu
- Neurological Intensive Care Unit, Beijing Chaoyang Integrative Medicine Emergency Medical Center, Beijing, China
| | - Weituo Zhang
- Clinical Research Institute, Shanghai Jiao Tong University/School of Medicine, Shanghai, China
| | - Chunlong Zhong
- Department of Neurosurgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Min Liu
- Department of Neurosurgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuhai Wang
- Department of Neurosurgery, Taihu Hospital, Wuxi, China
| | - Liansheng Long
- Department of Neurosurgery, South Taihu Hospital, Huzhou, China
| | - Ligang Chen
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jinfang Liu
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
| | - Chaohui Mou
- Department of Neurosurgery, Taizhou First People's Hospital, Zhejiang, China
| | - Binghui Qiu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xianjian Huang
- Department of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen, China
| | - Qibing Huang
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
| | - Nu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiaofeng Yang
- Emergency and Trauma Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - Chaohua Yang
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
| | - Lihong Li
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
| | - Rong Ma
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Xiang Wu
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Jin Lei
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
| | - Yong Jiang
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Liang Liu
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiyao Jiang
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
- Department of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen, China
- Emergency and Trauma Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
| | - the LTH-1 Trial collaborators
- Head Trauma Center, Department of Neurosurgery, Renji Hospital, Shanghai Jiao Tong University/School of Medicine, Shanghai Institute of Head Trauma, Shanghai, China
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Neurological Intensive Care Unit, Beijing Chaoyang Integrative Medicine Emergency Medical Center, Beijing, China
- Clinical Research Institute, Shanghai Jiao Tong University/School of Medicine, Shanghai, China
- Department of Neurosurgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of Neurosurgery, Taihu Hospital, Wuxi, China
- Department of Neurosurgery, South Taihu Hospital, Huzhou, China
- Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China
- Department of Neurosurgery, Xiangya Hospital, Central South University, Changsha, China
- Department of Neurosurgery, Taizhou First People's Hospital, Zhejiang, China
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
- Department of Neurosurgery, Shenzhen Second People's Hospital, Shenzhen, China
- Department of Neurosurgery, Qilu Hospital of Shandong University, Jinan, China
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
- Emergency and Trauma Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China
- Department of Neurosurgery, Tangdu Hospital, Xi'an, China
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25
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Gaither JB, Spaite DW, Bobrow BJ, Keim SM, Barnhart BJ, Chikani V, Sherrill D, Denninghoff KR, Mullins T, Adelson PD, Rice AD, Viscusi C, Hu C. Effect of Implementing the Out-of-Hospital Traumatic Brain Injury Treatment Guidelines: The Excellence in Prehospital Injury Care for Children Study (EPIC4Kids). Ann Emerg Med 2021; 77:139-153. [PMID: 33187749 PMCID: PMC7855946 DOI: 10.1016/j.annemergmed.2020.09.435] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 08/28/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We evaluate the effect of implementing the out-of-hospital pediatric traumatic brain injury guidelines on outcomes in children with major traumatic brain injury. METHODS The Excellence in Prehospital Injury Care for Children study is the preplanned secondary analysis of the Excellence in Prehospital Injury Care study, a multisystem, intention-to-treat study using a before-after controlled design. This subanalysis included children younger than 18 years who were transported to Level I trauma centers by participating out-of-hospital agencies between January 1, 2007, and June 30, 2015, throughout Arizona. The primary and secondary outcomes were survival to hospital discharge or admission for children with major traumatic brain injury and in 3 subgroups, defined a priori as those with moderate, severe, and critical traumatic brain injury. Outcomes in the preimplementation and postimplementation cohorts were compared with logistic regression, adjusting for risk factors and confounders. RESULTS There were 2,801 subjects, 2,041 in preimplementation and 760 in postimplementation. The primary analysis (postimplementation versus preimplementation) yielded an adjusted odds ratio of 1.16 (95% confidence interval 0.70 to 1.92) for survival to hospital discharge and 2.41 (95% confidence interval 1.17 to 5.21) for survival to hospital admission. In the severe traumatic brain injury cohort (Regional Severity Score-Head 3 or 4), but not the moderate or critical subgroups, survival to discharge significantly improved after guideline implementation (adjusted odds ratio = 8.42; 95% confidence interval 1.01 to 100+). The improvement in survival to discharge among patients with severe traumatic brain injury who received positive-pressure ventilation did not reach significance (adjusted odds ratio = 9.13; 95% confidence interval 0.79 to 100+). CONCLUSION Implementation of the pediatric out-of-hospital traumatic brain injury guidelines was not associated with improved survival when the entire spectrum of severity was analyzed as a whole (moderate, severe, and critical). However, both adjusted survival to hospital admission and discharge improved in children with severe traumatic brain injury, indicating a potential severity-based interventional opportunity for guideline effectiveness. These findings support the widespread implementation of the out-of-hospital pediatric traumatic brain injury guidelines.
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Affiliation(s)
- Joshua B Gaither
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ.
| | - Daniel W Spaite
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Bentley J Bobrow
- Department of Emergency Medicine, McGovern Medical School at UT Health, Houston, TX
| | - Samuel M Keim
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Bruce J Barnhart
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ
| | - Vatsal Chikani
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - Duane Sherrill
- Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
| | - Kurt R Denninghoff
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Terry Mullins
- Arizona Department of Health Services, Bureau of EMS, Phoenix, AZ
| | - P David Adelson
- Barrow Neurological Institute at Phoenix Children's Hospital and Department of Child Health/Neurosurgery, College of Medicine, The University of Arizona, Phoenix, AZ
| | - Amber D Rice
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chad Viscusi
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Department of Emergency Medicine, College of Medicine-Tucson, The University of Arizona, Tucson, AZ
| | - Chengcheng Hu
- Arizona Emergency Medicine Research Center, College of Medicine-Phoenix, The University of Arizona, Phoenix, AZ; Mel and Enid Zuckerman College of Public Health, The University of Arizona, Tucson, AZ
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Kamal VK, Pandey RM, Agrawal D. Development and temporal external validation of a simple risk score tool for prediction of outcomes after severe head injury based on admission characteristics from level-1 trauma centre of India using retrospectively collected data. BMJ Open 2021; 11:e040778. [PMID: 33455929 PMCID: PMC7813344 DOI: 10.1136/bmjopen-2020-040778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To develop and validate a simple risk scores chart to estimate the probability of poor outcomes in patients with severe head injury (HI). DESIGN Retrospective. SETTING Level-1, government-funded trauma centre, India. PARTICIPANTS Patients with severe HI admitted to the neurosurgery intensive care unit during 19 May 2010-31 December 2011 (n=946) for the model development and further, data from same centre with same inclusion criteria from 1 January 2012 to 31 July 2012 (n=284) for the external validation of the model. OUTCOMES In-hospital mortality and unfavourable outcome at 6 months. RESULTS A total of 39.5% and 70.7% had in-hospital mortality and unfavourable outcome, respectively, in the development data set. The multivariable logistic regression analysis of routinely collected admission characteristics revealed that for in-hospital mortality, age (51-60, >60 years), motor score (1, 2, 4), pupillary reactivity (none), presence of hypotension, basal cistern effaced, traumatic subarachnoid haemorrhage/intraventricular haematoma and for unfavourable outcome, age (41-50, 51-60, >60 years), motor score (1-4), pupillary reactivity (none, one), unequal limb movement, presence of hypotension were the independent predictors as its 95% confidence interval (CI) of odds ratio (OR)_did not contain one. The discriminative ability (area under the receiver operating characteristic curve (95% CI)) of the score chart for in-hospital mortality and 6 months outcome was excellent in the development data set (0.890 (0.867 to 912) and 0.894 (0.869 to 0.918), respectively), internal validation data set using bootstrap resampling method (0.889 (0.867 to 909) and 0.893 (0.867 to 0.915), respectively) and external validation data set (0.871 (0.825 to 916) and 0.887 (0.842 to 0.932), respectively). Calibration showed good agreement between observed outcome rates and predicted risks in development and external validation data set (p>0.05). CONCLUSION For clinical decision making, we can use of these score charts in predicting outcomes in new patients with severe HI in India and similar settings.
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Affiliation(s)
- Vineet Kumar Kamal
- Division of Epidemiology & Biostatistics, National Institute of Epidemiology, Indian Council of Medial Research (ICMR), Chennai, Tamil Nadu, India
| | - Ravindra Mohan Pandey
- Department of Biostatistics, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Deepak Agrawal
- Department of Neurosurgery, Jai Prakash Naryan Apex Trauma Centre, All India Institute of Medical Sciences (AIIMS), New Delhi, India
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Deng H, Zusman BE, Nwachuku EL, Yue JK, Chang YF, Conley YP, Okonkwo DO, Puccio AM. B-Cell Lymphoma 2 (Bcl-2) Gene Is Associated with Intracranial Hypertension after Severe Traumatic Brain Injury. J Neurotrauma 2021; 38:291-299. [PMID: 32515262 PMCID: PMC8182479 DOI: 10.1089/neu.2020.7028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Severe traumatic brain injury (TBI) activates the apoptotic cascade in neurons and glia as part of secondary cellular injury. B-cell lymphoma 2 (Bcl-2) gene encodes a pro-survival protein to suppress programmed cell death, and variation in this gene has potential to affect intracranial pressure (ICP). Participants were recruited from a single clinical center using a prospective observational study design. Inclusion criteria were: age 16-80 years; Glasgow Coma Scale (GCS) score 4-8; and at least 24 h of ICP monitoring treated between 2000-2014. Outcomes were mean ICP, spikes >20 and >25 mm Hg, edema, and surgical intervention. Odds ratios (OR), mean increases/decreases (B), and 95% confidence intervals (CIs) were reported. In 264 patients, average age was 39.2 years old and 78% of patients were male. Mean ICPs were 11.4 ± 0.4 mm Hg for patients with homozygous wild-type (AA), 12.8 ± 0.6 mm Hg for heterozygous (AG), and 14.3 ± 1.2 mm Hg for homozygous variant (GG; p = 0.023). Rs17759659 GG genotype was associated with more ICP spikes >20 mm Hg (p = 0.017) and >25 mm Hg (p = 0.048). Multi-variate analysis showed that GG relative to AA genotype had higher ICP (B = 2.7 mm Hg, 95% CI [0.5,4.9], p = 0.015), edema (OR = 2.5 [1.0, 6.0], p = 0.049) and need for decompression (OR = 3.7 [1.5-9.3], p = 0.004). In this prospective severe TBI cohort, Bcl-2 rs17759659 was associated with increased risk of intracranial hypertension, cerebral edema, and need for surgical intervention. The variant allele may impact programmed cell death of injured neurons, resulting in elevated ICP and post-traumatic secondary insults. Further risk stratification and targeted genotype-based therapies could improve outcomes after severe TBI.
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Affiliation(s)
- Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Benjamin E. Zusman
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Enyinna L. Nwachuku
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Department of Biostatistics and Epidemiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yvette P. Conley
- School of Nursing and Department of Human Genetics, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Neurotrauma Clinical Trials Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Jo K, Joo WI, Yoo DS, Park HK. Clinical Significance of Decompressive Craniectomy Surface Area and Side. J Korean Neurosurg Soc 2020; 64:261-270. [PMID: 33280352 PMCID: PMC7969045 DOI: 10.3340/jkns.2020.0149] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 07/02/2020] [Indexed: 11/27/2022] Open
Abstract
Objective Decompressive craniectomy (DC) can partially remove the unyielding skull vault and make affordable space for the expansion of swelling brain contents. The objective of this study was to compare clinical outcome according to DC surface area (DC area) and side.
Methods A total of 324 patients underwent different surgical methods (unilateral DC, 212 cases and bilateral DC, 112 cases) were included in this retrospective analysis. Their mean age was 53.4±16.6 years (median, 54 years). Neurological outcome (Glasgow outcome scale), ventricular intracranial pressure (ICP), and midline shift change (preoperative minus postoperative) were compared according to surgical methods and total DC area, DC surface removal rate (DC%) and side.
Results DC surgery was effective for ICP decrease (32.3±16.7 mmHg vs. 19.2±13.4 mmHg, p<0.001) and midline shift change (12.5±7.6 mm vs. 7.8±6.9 mm, p<0.001). The bilateral DC group showed larger total DC area (125.1±27.8 cm2 for unilateral vs. 198.2±43.0 cm2 for bilateral, p<0.001). Clinical outcomes were nonsignificant according to surgical side (favorable outcome, p=0.173 and mortality, p=0.470), significantly better when total DC area was over 160 cm2 and DC% was 46% (p=0.020 and p=0.037, respectively).
Conclusion DC surgery is effective in decrease the elevated ICP, decrease the midline shift and improve the clinical outcome in massive brain swelling patient. Total DC area and removal rate was larger in bilateral DC than unilateral DC but clinical outcome was not influenced by DC side. DC area more than 160 cm2 and DC surface removal rate more than 46% were more important than DC side.
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Affiliation(s)
- KwangWook Jo
- Department of Neurosurgery, Bucheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won Il Joo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Do Sung Yoo
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hae-Kwan Park
- Department of Neurosurgery, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Gamble M, Luggya TS, Mabweijano J, Nabulime J, Mowafi H. Impact of nursing education and a monitoring tool on outcomes in traumatic brain injury. Afr J Emerg Med 2020; 10:181-187. [PMID: 33299746 PMCID: PMC7700954 DOI: 10.1016/j.afjem.2020.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 05/19/2020] [Accepted: 05/29/2020] [Indexed: 11/18/2022] Open
Abstract
Introduction Throughout the world, traumatic brain injury (TBI) is one of the leading causes of morbidity and mortality. Low-and middle-income countries experience an especially high burden of TBI. While guidelines for TBI management exist in high income countries, little is known about the optimal management of TBI in low resource settings. Prevention of secondary injuries is feasible in these settings and has potential to improve mortality. Methods A pragmatic quasi-experimental study was conducted in the emergency centre (EC) of Mulago National Referral Hospital to evaluate the impact of TBI nursing education and use of a monitoring tool on mortality. Over 24 months, data was collected on 541 patients with moderate (GCS9-13) to severe (GCS≤8) TBI. The primary outcome was in-hospital mortality and secondary outcomes included time to imaging, time to surgical intervention, time to advanced airway, length of stay and number of vital signs recorded. Results Data were collected on 286 patients before the intervention and 255 after. Unadjusted mortality was higher in the post-intervention group but appeared to be related to severity of TBI, not the intervention itself. Apart from number of vital signs, secondary outcomes did not differ significantly between groups. In the post-intervention group, vital signs were recorded an average of 2.85 times compared to 0.49 in the pre-intervention group (95% CI 2.08-2.62, p ≤ 0.001). The median time interval between vital signs in the post-intervention group was 4.5 h (IQR 2.1-10.6). Conclusion Monitoring of vital signs in the EC improved with nursing education and use of a monitoring tool, however, there was no detectable impact on mortality. The high mortality among patients with TBI underscores the need for treatment strategies that can be implemented in low resource settings. Promising approaches include improved monitoring, organized trauma systems and protocols with an emphasis on early aggressive care and primary prevention.
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Li X, Lü C, Wang J, Wan Y, Dai SH, Zhang L, Hu XA, Jiang XF, Fei Z. Establishment and validation of a model for brain injury state evaluation and prognosis prediction. Chin J Traumatol 2020; 23:284-289. [PMID: 32928607 PMCID: PMC7567905 DOI: 10.1016/j.cjtee.2020.08.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Traumatic brain injury (TBI) is one of the leading causes of disability and death in modern times, whose evaluation and prognosis prediction have been one of the most critical issues in TBI management. However, the existed models for the abovementioned purposes were defective to varying degrees. This study aims to establish an ideal brain injury state clinical prediction model (BISCPM). METHODS This study was a retrospective design. The six-month outcomes of patients were selected as the end point event. BISCPM was established by using the split-sample technology, and externally validated via different tests of comparison between the observed and predicted six-month mortality in validating group. TBI patients admitted from July 2006 to June 2012 were recruited and randomly divided into establishing model group and validating model group. Twenty-one scoring indicators were included in BISCPM and divided into three parts, A, B, and C. Part A included movement, pupillary reflex and diameter, CT parameters, and secondary brain insult factors, etc. Part B was age and part C was medical history of the patients. The total score of part A, B and C was final score of BISCPM. RESULTS Altogether 1156 TBI patients were included with 578 cases in each group. The score of BISCPM from validating group ranged from 2.75 to 31.94, averaging 13.64 ± 5.59. There was not statistical difference between observed and predicted mortality for validating group. The discrimination validation showed that the BISCPM is superior to international mission for prognosis and analysis of clinical trials (IMPACT) lab model. CONCLUSION BISCPM is an effective model for state evaluation and prognosis prediction of TBI patients. The use of BISCPM could be of great significance for decision-making in management of TBI.
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Affiliation(s)
- Xia Li
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Chao Lü
- Neurosurgical Institute of PLA, Xi'an 710032, China
| | - Jun Wang
- Department of Digestive Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Yi Wan
- Department of Statistics, School of Preventive Medicine, Fourth Military Medical University, Xi'an 710032, China
| | - Shu-Hui Dai
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Lei Zhang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xue-An Hu
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Xiao-Fan Jiang
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China
| | - Zhou Fei
- Department of Neurosurgery, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China,Corresponding author.
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Bernstein JE, Ghanchi H, Kashyap S, Podkovik S, Miulli DE, Wacker MR, Sweiss R. Pentobarbital Coma With Therapeutic Hypothermia for Treatment of Refractory Intracranial Hypertension in Traumatic Brain Injury Patients: A Single Institution Experience. Cureus 2020; 12:e10591. [PMID: 33110727 PMCID: PMC7581220 DOI: 10.7759/cureus.10591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 09/22/2020] [Indexed: 01/23/2023] Open
Abstract
Introduction Traumatic brain injury (TBI) results in primary and secondary brain injuries. Secondary brain injury can lead to cerebral edema resulting in increased intracranial pressure (ICP) secondary to the rigid encasement of the skull. Increased ICP leads to decreased cerebral perfusion pressure which leads to cerebral ischemia. Refractory intracranial hypertension (RICH) occurs when ICP remains elevated despite first-tier therapies such as head elevation, straightening of the neck, analgesia, sedation, paralytics, cerebrospinal fluid (CSF) drainage, mannitol and/or hypertonic saline administration. If unresponsive to these measures, second-tier therapies such as hypothermia, barbiturate infusion, and/or surgery are employed. Methods This was a retrospective review of patients admitted at Arrowhead Regional Medical Center from 2008 to 2019 for severe TBI who developed RICH requiring placement into a pentobarbital-induced coma with therapeutic hypothermia. Primary endpoints included mortality, good recovery which was designated at Glasgow outcome scale (GOS) of 4 or 5, and improvement in ICP (goal is <20 mmHg). Secondary endpoints included complications, length of intensive care unit (ICU) stay, length of hospital stay, length of pentobarbital coma, length of hypothermia, need for vasopressors, and decompressive surgery versus no decompressive surgery. Results Our study included 18 patients placed in pentobarbital coma with hypothermia for RICH. The overall mortality rate in our study was 50%; with 60% mortality in pentobarbital/hypothermia only group, and 46% mortality in surgery plus pentobarbital/hypothermia group. Maximum ICP prior to pentobarbital/hypothermia was significantly lower in patients who had a prior decompressive craniectomy than in patients who were placed into pentobarbital/hypothermia protocol first (28.3 vs 35.4, p<0.0238). ICP was significantly reduced at 4 hours, 8 hours, 12 hours, 24 hours, and 48 hours after pentobarbital and hypothermia treatment. Initial ICP and maximum ICP prior to pentobarbital/hypothermia was significantly correlated with mortality (p=0.022 and p=0.026). Patients with an ICP>25 mmHg prior to pentobarbital/hypothermia initiation had an increased risk of mortality (p=0.0455). There was no statistically significant difference in mean ICP after 24 hours after pentobarbital/hypothermia protocol in survivors vs non-survivors. Increased time to reach 33°C was associated with increased mortality (r=0.47, p=0.047); with a 10.5-fold increase in mortality for >7 hours (OR 10.5, p=0.039). Conclusion Prolonged cooling time >7 hours was associated with a 10.5-fold increase in mortality and ICP>25 mmHg prior to initiation of pentobarbital and hypothermia is suggestive of a poor response to treatment. We recommend patients with severe TBI who develop RICH should first undergo a 12 x 15 cm decompressive hemicraniectomy because they have better survival and are more likely to have ICP <25 mmHg as the highest elevation of ICP if the ICP were to become and stay elevated again. Pentobarbital and hypothermia should be initiated if the ICP becomes elevated and sustained above 20 mmHg with a prior decompressive hemicraniectomy and refractory to other medical therapies. However, our data suggests that patients are unlikely to survive if there ICP does not decrease to less than 15mmHg at 8 and 12 hours after pentobarbital/hypothermia and remain less than 20 mmHg within first 48 hours.
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Affiliation(s)
- Jacob E Bernstein
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Hammad Ghanchi
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Samir Kashyap
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Stacey Podkovik
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | | | - Raed Sweiss
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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Cooper S, Bendinelli C, Bivard A, Parsons M, Balogh ZJ. Abnormalities on Perfusion CT and Intervention for Intracranial Hypertension in Severe Traumatic Brain Injury. J Clin Med 2020; 9:E2000. [PMID: 32630511 PMCID: PMC7356931 DOI: 10.3390/jcm9062000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 11/16/2022] Open
Abstract
The role of invasive intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (STBI) remain unclear. Perfusion computed tomography (CTP) provides crucial information about the cerebral perfusion status in these patients. We hypothesised that CTP abnormalities would be associated with the severity of intracranial hypertension (ICH). To investigate this hypothesis, twenty-eight patients with STBI and ICP monitors were investigated with CTP within 48 h from admission. Treating teams were blind to these results. Patients were divided into five groups based on increasing intervention required to control ICH and were compared. Group I required no intervention above routine sedation, group II required a single first tier intervention, group III required multiple different first-tier interventions, group IV required second-tier medical therapy and group V required second-tier surgical therapy. Analysis of the results showed demographics and injury severity did not differ among groups. In group I no patients showed CTP abnormality, while patients in all other groups had abnormal CTP (p = 0.003). Severe ischaemia observed on CTP was associated with increasing intervention for ICH. This study, although limited by small sample size, suggests that CTP abnormalities are associated with the need to intervene for ICH. Larger scale assessment of our results is warranted to potentially avoid unnecessary invasive procedures in head injury patients.
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Affiliation(s)
- Shannon Cooper
- Department of Traumatology, John Hunter Hospital Newcastle, Newcastle, NSW 2305, Australia; (S.C.); (C.B.)
| | - Cino Bendinelli
- Department of Traumatology, John Hunter Hospital Newcastle, Newcastle, NSW 2305, Australia; (S.C.); (C.B.)
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2300, Australia; (A.B.); (M.P.)
| | - Andrew Bivard
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2300, Australia; (A.B.); (M.P.)
- Department of Neurology, University of Melbourne, Melbourne, VIC 3050, Australia
| | - Mark Parsons
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2300, Australia; (A.B.); (M.P.)
- Department of Neurology, University of Melbourne, Melbourne, VIC 3050, Australia
| | - Zsolt J. Balogh
- Department of Traumatology, John Hunter Hospital Newcastle, Newcastle, NSW 2305, Australia; (S.C.); (C.B.)
- School of Medicine and Public Health, University of Newcastle, Newcastle, NSW 2300, Australia; (A.B.); (M.P.)
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Ozoner B, Kilic M, Aydin L, Aydin S, Arslan YK, Musluman AM, Yilmaz A. Early cranioplasty associated with a lower rate of post-traumatic hydrocephalus after decompressive craniectomy for traumatic brain injury. Eur J Trauma Emerg Surg 2020; 46:919-926. [PMID: 32494837 DOI: 10.1007/s00068-020-01409-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/22/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Post-traumatic hydrocephalus (PTH) is one of the primary complications during the course of traumatic brain injury (TBI). The aim of this study was to define factors associated with the development of PTH in patients who underwent unilateral decompressive craniectomy (DC) for TBI. METHODS A total of 126 patients, who met the inclusion criteria of the study, were divided into two groups: patients with PTH (n = 25) and patients without PTH (n = 101). Their demographic, clinical, radiological, operative, and postoperative factors, which may be associated with the development of PTH, were compared. RESULTS Multivariate logistic regression analysis revealed that cranioplasty performed later than 2 months following DC was significantly associated with the requirement for ventriculoperitoneal shunting due to PTH (p < 0.001). Also, a significant unfavorable outcome rate was observed in patients with PTH at 1-year follow-up according to the Glasgow Outcome Scale-Extended (p = 0.047). CONCLUSIONS Our results show that early cranioplasty within 2 months after DC was associated with a lower rate of PTH development after TBI.
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Affiliation(s)
- Baris Ozoner
- Department of Neurosurgery, School of Medicine, Bahcesehir University, Istanbul, Turkey. .,School of Medicine, Department of Neurosurgery, Erzincan Binali Yildirim University, Erzincan, Turkey.
| | - Mustafa Kilic
- Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Levent Aydin
- Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Seckin Aydin
- Department of Neurosurgery, Okmeydani Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Yusuf Kemal Arslan
- Department of Biostatistics, School of Medicine, Erzincan Binali Yildirim University, Erzincan, Turkey
| | - Ahmet Murat Musluman
- Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
| | - Adem Yilmaz
- Department of Neurosurgery, Sisli Hamidiye Etfal Research and Education Hospital, University of Medical Sciences, Istanbul, Turkey
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Evensen KB, Eide PK. Measuring intracranial pressure by invasive, less invasive or non-invasive means: limitations and avenues for improvement. Fluids Barriers CNS 2020; 17:34. [PMID: 32375853 PMCID: PMC7201553 DOI: 10.1186/s12987-020-00195-3] [Citation(s) in RCA: 79] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/19/2020] [Indexed: 12/20/2022] Open
Abstract
Sixty years have passed since neurosurgeon Nils Lundberg presented his thesis about intracranial pressure (ICP) monitoring, which represents a milestone for its clinical introduction. Monitoring of ICP has since become a clinical routine worldwide, and today represents a cornerstone in surveillance of patients with acute brain injury or disease, and a diagnostic of individuals with chronic neurological disease. There is, however, controversy regarding indications, clinical usefulness and the clinical role of the various ICP scores. In this paper, we critically review limitations and weaknesses with the current ICP measurement approaches for invasive, less invasive and non-invasive ICP monitoring. While risk related to the invasiveness of ICP monitoring is extensively covered in the literature, we highlight other limitations in current ICP measurement technologies, including limited ICP source signal quality control, shifts and drifts in zero pressure reference level, affecting mean ICP scores and mean ICP-derived indices. Control of the quality of the ICP source signal is particularly important for non-invasive and less invasive ICP measurements. We conclude that we need more focus on mitigation of the current limitations of today's ICP modalities if we are to improve the clinical utility of ICP monitoring.
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Affiliation(s)
- Karen Brastad Evensen
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway
- Department of Informatics, Faculty of Mathematics and Natural Sciences, University of Oslo, Oslo, Norway
| | - Per Kristian Eide
- Department of Neurosurgery, Oslo University Hospital-Rikshospitalet, P.O. Box 4950, Nydalen, 0424, Oslo, Norway.
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
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Karakasi MV, Nikova AS, Valsamidou C, Pavlidis P, Birbilis TA. Anatomical Localization of Traumatic Brain Injury Cases in Eastern Macedonia and Thrace, Greece: a 10-year Retrospective Observational Study. Korean J Neurotrauma 2020; 16:38-48. [PMID: 32395450 PMCID: PMC7192809 DOI: 10.13004/kjnt.2020.16.e6] [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: 09/23/2019] [Revised: 03/13/2020] [Accepted: 03/18/2020] [Indexed: 11/15/2022] Open
Abstract
Objective Brain trauma is an extremely important economical and social issue with increasing daily incidence. It is important to observe and report brain trauma, in order to provide better conditions for improvement of the trauma prevention and management. Methods A ten-year retrospective observational analysis was performed on 292 (fatal and non-fatal) incidents of traumatic brain injury among 2,847 totally examined cases in the records of the laboratory of forensic sciences at Democritus University of Thrace between January 1, 2007 and December 31, 2016. The results were further analyzed and classified into pertinent categories associated with the purpose of the study. Results The average age was estimated at 47.24 years with an obvious male domination. The most common cause of TBI, according to the results, is transport accidents (61.85%) followed by trauma inflicted by blunt instrument (22.49%), fall from height (11.65%) and occupational accidents (4.02%). Mortality rates were evaluated for each type, revealing extremely disturbing numbers. Regarding the anatomical localization on the skull, the most common region of cranial fractures is the cranial base (16.48%), followed by the frontal (12.87%), occipital (11.29%) and parietal bones (11.06%). In the majority of the cases, there were associated injuries. Conclusion The management of traumatic brain injuries is difficult and sometimes impossible. Better prevention measures are required to minimize as much as possible the incidence of brain trauma.
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Affiliation(s)
- Maria-Valeria Karakasi
- Laboratory of Forensic Sciences, Democritus University of Thrace, School of Medicine, Dragana, Alexandroupolis, Greece
| | - Alexandrina S. Nikova
- Department of Neurosurgery, Democritus University of Thrace, School of Medicine, Dragana, Alexandroupolis, Greece
| | - Christina Valsamidou
- Laboratory of Forensic Sciences, Democritus University of Thrace, School of Medicine, Dragana, Alexandroupolis, Greece
| | - Pavlos Pavlidis
- Laboratory of Forensic Sciences, Democritus University of Thrace, School of Medicine, Dragana, Alexandroupolis, Greece
| | - Theodossios A. Birbilis
- Department of Neurosurgery, Democritus University of Thrace, School of Medicine, Dragana, Alexandroupolis, Greece
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Management and outcomes following emergency surgery for traumatic brain injury - A multi-centre, international, prospective cohort study (the Global Neurotrauma Outcomes Study). Int J Surg Protoc 2020; 20:1-7. [PMID: 32211566 PMCID: PMC7082548 DOI: 10.1016/j.isjp.2020.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 02/09/2020] [Indexed: 12/05/2022] Open
Abstract
An estimated 27 million traumatic brain injuries (TBIs) occur worldwide every year. In certain cases, neurosurgical intervention for TBI is necessary and life-saving. The timing and quality of surgery for TBI has long been known to dramatically affect outcome. There is a paucity of data on outcomes following neurosurgery globally. GNOS will compare outcomes following emergency surgery for TBI worldwide. Introduction Traumatic brain injury (TBI) accounts for a significant amount of death and disability worldwide and the majority of this burden affects individuals in low-and-middle income countries. Despite this, considerable geographical differences have been reported in the care of TBI patients. On this background, we aim to provide a comprehensive international picture of the epidemiological characteristics, management and outcomes of patients undergoing emergency surgery for traumatic brain injury (TBI) worldwide. Methods and analysis The Global Neurotrauma Outcomes Study (GNOS) is a multi-centre, international, prospective observational cohort study. Any unit performing emergency surgery for TBI worldwide will be eligible to participate. All TBI patients who receive emergency surgery in any given consecutive 30-day period beginning between 1st of November 2018 and 31st of December 2019 in a given participating unit will be included. Data will be collected via a secure online platform in anonymised form. The primary outcome measures for the study will be 14-day mortality (or survival to hospital discharge, whichever comes first). Final day of data collection for the primary outcome measure is February 13th. Secondary outcome measures include return to theatre and surgical site infection. Ethics and dissemination This project will not affect clinical practice and has been classified as clinical audit following research ethics review. Access to source data will be made available to collaborators through national or international anonymised datasets on request and after review of the scientific validity of the proposed analysis by the central study team.
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Delaplain PT, Grigorian A, Lekawa M, Mallicote M, Joe V, Schubl SD, Kuza CM, Dolich M, Nahmias J. Intracranial pressure monitoring associated with increased mortality in pediatric brain injuries. Pediatr Surg Int 2020; 36:391-398. [PMID: 31938835 PMCID: PMC7223517 DOI: 10.1007/s00383-020-04618-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/03/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Utilization of ICP monitors for pediatric patients is low and varies between centers. We hypothesized that in more severely injured patients (GCS 3-4), there would be a decreased mortality associated with invasive monitoring devices. METHODS The pediatric Trauma Quality Improvement Program (TQIP) was queried for patients aged ≤ 16 years meeting criteria for invasive monitors. Our primary outcome was mortality. Patients with ICP monitoring were compared to those without. A logistic regression was used to examine the risk of mortality. RESULTS Of 3,808 patients, 685 (18.0%) underwent ICP monitoring. ICP monitors were associated with increased risk of mortality (OR 1.82, CI 1.36-2.44, p < 0.001). A secondary analysis including type of invasive ICP monitor and dividing GCS into 3 categories revealed both intraventricular drain (OR 1.89, CI 1.3-2.7, p = 0.001) and intraparenchymal pressure monitor (OR 1.86, CI 1.32-2.6, p < 0.001) to be independently associated with an increased likelihood of mortality regardless of GCS, while intraparenchymal oxygen monitoring was not (OR 0.47, CI 0.11-2.05, p = 0.316). The strongest effect was seen in those patients with a GCS of 5-6. CONCLUSION ICP monitors are an independent risk factor for mortality, particularly with intraventricular drains and intraparenchymal monitors in patients with a GCS 5-6.
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Affiliation(s)
- Patrick T Delaplain
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA.
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Michael Lekawa
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Michael Mallicote
- Department of Pediatric Surgery, Children's Hospital Los Angeles, 4650 Sunset Blvd., Mailstop #100, Los Angeles, CA, 90027, USA
| | - Victor Joe
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Sebastian D Schubl
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Catherine M Kuza
- Department of Anesthesiology, University of Southern California, 1450 San Pablo Street Suite 360, Los Angeles, CA, 90033, USA
| | - Matthew Dolich
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
| | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine Medical Center, 333 City Blvd West, Suite 1600, Orange, CA, 92868, USA
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Integrative Analysis of Circulating Metabolite Profiles and Magnetic Resonance Imaging Metrics in Patients with Traumatic Brain Injury. Int J Mol Sci 2020; 21:ijms21041395. [PMID: 32092929 PMCID: PMC7073036 DOI: 10.3390/ijms21041395] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Revised: 02/13/2020] [Accepted: 02/15/2020] [Indexed: 12/19/2022] Open
Abstract
Recent evidence suggests that patients with traumatic brain injuries (TBIs) have a distinct circulating metabolic profile. However, it is unclear if this metabolomic profile corresponds to changes in brain morphology as observed by magnetic resonance imaging (MRI). The aim of this study was to explore how circulating serum metabolites, following TBI, relate to structural MRI (sMRI) findings. Serum samples were collected upon admission to the emergency department from patients suffering from acute TBI and metabolites were measured using mass spectrometry-based metabolomics. Most of these patients sustained a mild TBI. In the same patients, sMRIs were taken and volumetric data were extracted (138 metrics). From a pool of 203 eligible screened patients, 96 met the inclusion criteria for this study. Metabolites were summarized as eight clusters and sMRI data were reduced to 15 independent components (ICs). Partial correlation analysis showed that four metabolite clusters had significant associations with specific ICs, reflecting both the grey and white matter brain injury. Multiple machine learning approaches were then applied in order to investigate if circulating metabolites could distinguish between positive and negative sMRI findings. A logistic regression model was developed, comprised of two metabolic predictors (erythronic acid and myo-inositol), which, together with neurofilament light polypeptide (NF-L), discriminated positive and negative sMRI findings with an area under the curve of the receiver-operating characteristic of 0.85 (specificity = 0.89, sensitivity = 0.65). The results of this study show that metabolomic analysis of blood samples upon admission, either alone or in combination with protein biomarkers, can provide valuable information about the impact of TBI on brain structural changes.
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Lorente L, Martín MM, Pérez-Cejas A, González-Rivero AF, Abreu-González P, Ramos L, Argueso M, Solé-Violán J, Cáceres JJ, Jiménez A, García-Marín V. Traumatic Brain Injury Patients Mortality and Serum Total Antioxidant Capacity. Brain Sci 2020; 10:brainsci10020110. [PMID: 32085496 PMCID: PMC7071510 DOI: 10.3390/brainsci10020110] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/29/2020] [Accepted: 02/15/2020] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVE Oxidation is involved in secondary brain injury after traumatic brain injury (TBI). Increased concentrations of total antioxidant capacity (TAC) in blood at the time of admission for TBI have been found in non-surviving patients. The main objective of this study was to determine the role of serum TAC levels at any time during the first week of TBI for the prediction of early mortality. METHODS Isolated (<10 points in non-cranial aspects of Injury Severity Score) and severe (<9 points in Glasgow Coma Scale) TBI patients were included. Serum TAC concentrations at days 1, 4, and 8 of TBI were determined. The end-point study was 30-day mortality. RESULTS Higher serum TAC levels at days 1 (p < 0.001), 4 (p < 0.001), and 8 (p = 0.002) of TBI were found in non-surviving (n = 34) than in surviving patients (n = 90). The area under curve (95% Confidence Interval) for prediction of 30-day mortality by serum TAC concentrations at days 1, 4, and 8 of TBI were 0.79 (0.71-0.86; p < 0.001), 0.87 (0.79-0.93; p < 0.001), and 0.76 (0.67-0.84; p = 0.006) respectively. CONCLUSIONS The novelty of our study was the ability to predict 30-day mortality by serum TAC concentrations at any time during the first week of TBI.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, 38320 Ofra s/n. La Laguna, Spain
- Correspondence:
| | - María M. Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora de Candelaria, 38020 Crta del Rosario s/n., Spain;
| | - Antonia Pérez-Cejas
- Laboratory Department, Hospital Universitario de Canarias, 38320 Ofra s/n. La Laguna, Spain; (A.P.-C.); (A.F.G.-R.)
| | - Agustín F. González-Rivero
- Laboratory Department, Hospital Universitario de Canarias, 38320 Ofra s/n. La Laguna, Spain; (A.P.-C.); (A.F.G.-R.)
| | - Pedro Abreu-González
- Department of Physiology, Faculty of Medicine, University of the La Laguna, 38320 Ofra s/n. La Laguna, Spain;
| | - Luis Ramos
- Intensive Care Unit, Hospital General La Palma, 38713 Buenavista de Arriba s/n., Spain;
| | - Mónica Argueso
- Intensive Care Unit, Hospital Clínico Universitario de Valencia, Avda, Blasco Ibáñez nº17-19, 46004 Valencia, Spain;
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, CIBERES, 35010 Barranco de la Ballena s/n. Las Palmas de Gran Canaria, Spain;
| | - Juan J. Cáceres
- Intensive Care Unit, Hospital Insular. Plaza Dr. Pasteur, 35016 s/n. Las Palmas de Gran Canaria, Spain;
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, 38320 Ofra s/n. La Laguna, Spain;
| | - Victor García-Marín
- Department of Neurosurgery, Hospital Universitario de Canarias, 38320 Ofra s/n. La Laguna, Spain;
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Potential Therapeutic Approaches Against Brain Diseases Associated with Cytomegalovirus Infections. Int J Mol Sci 2020; 21:ijms21041376. [PMID: 32085671 PMCID: PMC7073089 DOI: 10.3390/ijms21041376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/29/2020] [Accepted: 02/15/2020] [Indexed: 11/28/2022] Open
Abstract
Cytomegalovirus (CMV) is one of the major human health threats worldwide, especially for immunologically comprised patients. CMV may cause opportunistic infections, congenital infections, and brain diseases (e.g., mental retardation and glioblastoma). The etiology of brain diseases associated with human CMV (HCMV) infections is usually complex and it is particularly difficult to treat because HCMV has a life-long infection in its hosts, high mutation rate, and latent infections. Moreover, it is almost impossible to eradicate latent viruses in humans. Although there has been progress in drug discovery recently, current drugs used for treating active CMV infections are still limited in efficacy due to side effects, toxicity, and viral resistance. Fortunately, letermovir which targets the HCMV terminase complex rather than DNA polymerase with fewer adverse reactions has been approved to treat CMV infections in humans. The researchers are focusing on developing approaches against both productive and latent infections of CMV. The gene or RNA targeting approaches including the external guide sequences (EGSs)-RNase, the clustered regularly interspaced short palindromic repeats (CRISPR)/CRISPR-associated protein 9 (Cas9) system and transcription activator-like effector nucleases (TALENs) are being investigated to remove acute and/or latent CMV infections. For the treatment of glioblastoma, vaccine therapy through targeting specific CMV antigens has improved patients’ survival outcomes significantly and immunotherapy has also emerged as an alternative modality. The advanced research for developing anti-CMV agents and approaches is promising to obtain significant outcomes and expecting to have a great impact on the therapy of brain diseases associated with CMV infections.
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The Effect of Goal-Directed Therapy on Patient Morbidity and Mortality After Traumatic Brain Injury: Results From the Progesterone for the Treatment of Traumatic Brain Injury III Clinical Trial. Crit Care Med 2020; 47:623-631. [PMID: 30730438 DOI: 10.1097/ccm.0000000000003680] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To estimate the impact of goal-directed therapy on outcome after traumatic brain injury, our team applied goal-directed therapy to standardize care in patients with moderate to severe traumatic brain injury, who were enrolled in a large multicenter clinical trial. DESIGN Planned secondary analysis of data from Progesterone for the Treatment of Traumatic Brain Injury III, a large, prospective, multicenter clinical trial. SETTING Forty-two trauma centers within the Neurologic Emergencies Treatment Trials network. PATIENTS Eight-hundred eighty-two patients were enrolled within 4 hours of injury after nonpenetrating traumatic brain injury characterized by Glasgow Coma Scale score of 4-12. MEASUREMENTS AND MAIN RESULTS Physiologic goals were defined a priori in order to standardize care across 42 sites participating in Progesterone for the Treatment of Traumatic Brain Injury III. Physiologic data collection occurred hourly; laboratory data were collected according to local ICU protocols and at a minimum of once per day. Physiologic transgressions were predefined as substantial deviations from the normal range of goal-directed therapy. Each hour where goal-directed therapy was not achieved was classified as a "transgression." Data were adjudicated electronically and via expert review. Six-month outcomes included mortality and the stratified dichotomy of the Glasgow Outcome Scale-Extended. For each variable, the association between outcome and either: 1) the occurrence of a transgression or 2) the proportion of time spent in transgression was estimated via logistic regression model. RESULTS For the 882 patients enrolled in Progesterone for the Treatment of Traumatic Brain Injury III, mortality was 12.5%. Prolonged time spent in transgression was associated with increased mortality in the full cohort for hemoglobin less than 8 gm/dL (p = 0.0006), international normalized ratio greater than 1.4 (p < 0.0001), glucose greater than 180 mg/dL (p = 0.0003), and systolic blood pressure less than 90 mm Hg (p < 0.0001). In the patient subgroup with intracranial pressure monitoring, prolonged time spent in transgression was associated with increased mortality for intracranial pressure greater than or equal to 20 mm Hg (p < 0.0001), glucose greater than 180 mg/dL (p = 0.0293), hemoglobin less than 8 gm/dL (p = 0.0220), or systolic blood pressure less than 90 mm Hg (p = 0.0114). Covariates inversely related to mortality included: a single occurrence of mean arterial pressure less than 65 mm Hg (p = 0.0051) or systolic blood pressure greater than 180 mm Hg (p = 0.0002). CONCLUSIONS The Progesterone for the Treatment of Traumatic Brain Injury III clinical trial rigorously monitored compliance with goal-directed therapy after traumatic brain injury. Multiple significant associations between physiologic transgressions, morbidity, and mortality were observed. These data suggest that effective goal-directed therapy in traumatic brain injury may provide an opportunity to improve patient outcomes.
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Guerra SD, Ferreira AR. EVENTS ASSOCIATED WITH THE OCCURRENCE OF INTRACRANIAL HYPERTENSION IN PEDIATRIC PATIENTS WITH SEVERE CRANIOENCEPHALIC TRAUMA AND MONITORING OF INTRACRANIAL PRESSURE. REVISTA PAULISTA DE PEDIATRIA 2020; 38:e2019123. [PMID: 31939519 PMCID: PMC6958539 DOI: 10.1590/1984-0462/2020/38/2019123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/21/2019] [Indexed: 11/22/2022]
Abstract
Objective: To determine the events associated with the occurrence of intracranial hypertension (ICH) in pediatric patients with severe cranioencephalic trauma. Methods: This was a prospective cohort study of patients 18 years old and younger with cranioencephalic trauma, scores below nine on the Glasgow Coma Scale, and intracranial pressure monitoring. They were admitted between September, 2005 and March, 2014 into a Pediatric Intensive Care Unit. ICH was defined as an episode of intracranial pressure above 20 mmHg for more than five minutes that needed treatment. Results: A total of 198 children and adolescents were included in the study, of which 70.2% were males and there was a median age of nine years old. ICH occurred in 135 (68.2%) patients and maximum intracranial pressure was 36.3 mmHg, with a median of 34 mmHg. A total of 133 (97.8%) patients with ICH received sedation and analgesia for treatment of the condition, 108 (79.4%) received neuromuscular blockers, 7 (5.2%) had cerebrospinal fluid drainage, 105 (77.2%) received mannitol, 96 (70.6%) received hyperventilation, 64 (47.1%) received 3% saline solution, 20 (14.7%) received barbiturates, and 43 (31.9%) underwent a decompressive craniectomy. The events associated with the occurrence of ICH were tomographic findings at the time of admission of diffuse or hemispheric swelling (edema plus engorgement). The odds ratio for ICH in patients with Marshall III (diffuse swelling) tomography was 14 (95%CI 2.8–113; p<0.003), and for those with Marshall IV (hemispherical swelling) was 24.9 (95%CI 2.4–676, p<0.018). Mortality was 22.2%. Conclusions: Pediatric patients with severe cranioencephalic trauma and tomographic alterations of Marshall III and IV presented a high chance of developing ICH.
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Sahuquillo J, Dennis JA, Cochrane Injuries Group. Decompressive craniectomy for the treatment of high intracranial pressure in closed traumatic brain injury. Cochrane Database Syst Rev 2019; 12:CD003983. [PMID: 31887790 PMCID: PMC6953357 DOI: 10.1002/14651858.cd003983.pub3] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND High intracranial pressure (ICP) is the most frequent cause of death and disability after severe traumatic brain injury (TBI). It is usually treated with general maneuvers (normothermia, sedation, etc.) and a set of first-line therapeutic measures (moderate hypocapnia, mannitol, etc.). When these measures fail, second-line therapies are initiated, which include: barbiturates, hyperventilation, moderate hypothermia, or removal of a variable amount of skull bone (secondary decompressive craniectomy). OBJECTIVES To assess the effects of secondary decompressive craniectomy (DC) on outcomes of patients with severe TBI in whom conventional medical therapeutic measures have failed to control raised ICP. SEARCH METHODS The most recent search was run on 8 December 2019. We searched the Cochrane Injuries Group's Specialised Register, CENTRAL (Cochrane Library), Ovid MEDLINE(R), Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations, Ovid MEDLINE(R) Daily and Ovid OLDMEDLINE(R), Embase Classic + Embase (OvidSP) and ISI Web of Science (SCI-EXPANDED & CPCI-S). We also searched trials registries and contacted experts. SELECTION CRITERIA We included randomized studies assessing patients over the age of 12 months with severe TBI who either underwent DC to control ICP refractory to conventional medical treatments or received standard care. DATA COLLECTION AND ANALYSIS We selected potentially relevant studies from the search results, and obtained study reports. Two review authors independently extracted data from included studies and assessed risk of bias. We used a random-effects model for meta-analysis. We rated the quality of the evidence according to the GRADE approach. MAIN RESULTS We included three trials (590 participants). One single-site trial included 27 children; another multicenter trial (three countries) recruited 155 adults, the third trial was conducted in 24 countries, and recruited 408 adolescents and adults. Each study compared DC combined with standard care (this could include induced barbiturate coma or cooling of the brain, or both). All trials measured outcomes up to six months after injury; one also measured outcomes at 12 and 24 months (the latter data remain unpublished). All trials were at a high risk of bias for the criterion of performance bias, as neither participants nor personnel could be blinded to these interventions. The pediatric trial was at a high risk of selection bias and stopped early; another trial was at risk of bias because of atypical inclusion criteria and a change to the primary outcome after it had started. Mortality: pooled results for three studies provided moderate quality evidence that risk of death at six months was slightly reduced with DC (RR 0.66, 95% CI 0.43 to 1.01; 3 studies, 571 participants; I2 = 38%; moderate-quality evidence), and one study also showed a clear reduction in risk of death at 12 months (RR 0.59, 95% CI 0.45 to 0.76; 1 study, 373 participants; high-quality evidence). Neurological outcome: conscious of controversy around the traditional dichotomization of the Glasgow Outcome Scale (GOS) scale, we chose to present results in three ways, in order to contextualize factors relevant to clinical/patient decision-making. First, we present results of death in combination with vegetative status, versus other outcomes. Two studies reported results at six months for 544 participants. One employed a lower ICP threshold than the other studies, and showed an increase in the risk of death/vegetative state for the DC group. The other study used a more conventional ICP threshold, and results favoured the DC group (15.7% absolute risk reduction (ARR) (95% CI 6% to 25%). The number needed to treat for one beneficial outcome (NNTB) (i.e. to avoid death or vegetative status) was seven. The pooled result for DC compared with standard care showed no clear benefit for either group (RR 0.99, 95% CI 0.46 to 2.13; 2 studies, 544 participants; I2 = 86%; low-quality evidence). One study reported data for this outcome at 12 months, when the risk for death or vegetative state was clearly reduced by DC compared with medical treatment (RR 0.68, 95% CI 0.54 to 0.86; 1 study, 373 participants; high-quality evidence). Second, we assessed the risk of an 'unfavorable outcome' evaluated on a non-traditional dichotomized GOS-Extended scale (GOS-E), that is, grouping the category 'upper severe disability' into the 'good outcome' grouping. Data were available for two studies (n = 571). Pooling indicated little difference between DC and standard care regarding the risk of an unfavorable outcome at six months following injury (RR 1.06, 95% CI 0.69 to 1.63; 544 participants); heterogeneity was high, with an I2 value of 82%. One trial reported data at 12 months and indicated a clear benefit of DC (RR 0.81, 95% CI 0.69 to 0.95; 373 participants). Third, we assessed the risk of an 'unfavorable outcome' using the (traditional) dichotomized GOS/GOS-E cutoff into 'favorable' versus 'unfavorable' results. There was little difference between DC and standard care at six months (RR 1.00, 95% CI 0.71 to 1.40; 3 studies, 571 participants; low-quality evidence), and heterogeneity was high (I2 = 78%). At 12 months one trial suggested a similar finding (RR 0.95, 95% CI 0.83 to 1.09; 1 study, 373 participants; high-quality evidence). With regard to ICP reduction, pooled results for two studies provided moderate quality evidence that DC was superior to standard care for reducing ICP within 48 hours (MD -4.66 mmHg, 95% CI -6.86 to -2.45; 2 studies, 182 participants; I2 = 0%). Data from the third study were consistent with these, but could not be pooled. Data on adverse events are difficult to interpret, as mortality and complications are high, and it can be difficult to distinguish between treatment-related adverse events and the natural evolution of the condition. In general, there was low-quality evidence that surgical patients experienced a higher risk of adverse events. AUTHORS' CONCLUSIONS Decompressive craniectomy holds promise of reduced mortality, but the effects of long-term neurological outcome remain controversial, and involve an examination of the priorities of participants and their families. Future research should focus on identifying clinical and neuroimaging characteristics to identify those patients who would survive with an acceptable quality of life; the best timing for DC; the most appropriate surgical techniques; and whether some synergistic treatments used with DC might improve patient outcomes.
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Affiliation(s)
- Juan Sahuquillo
- Vall d'Hebron University HospitalDepartment of NeurosurgeryUniversitat Autònoma de BarcelonaPaseo Vall d'Hebron 119 ‐ 129BarcelonaBarcelonaSpain08035
| | - Jane A Dennis
- University of BristolMusculoskeletal Research Unit, School of Clinical SciencesLearning and Research Building [Level 1]Southmead HospitalBristolUKBS10 5NB
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Bouras M, Roquilly A, Mahé PJ, Cinotti R, Vourc'h M, Perrot B, Bach-Ngohou K, Masson D, Asehnoune K. Cortisol total/CRP ratio for the prediction of hospital-acquired pneumonia and initiation of corticosteroid therapy in traumatic brain-injured patients. Crit Care 2019; 23:394. [PMID: 31805967 PMCID: PMC6896691 DOI: 10.1186/s13054-019-2680-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/20/2019] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND To propose a combination of blood biomarkers for the prediction of hospital-acquired pneumonia (HAP) and for the selection of traumatic brain-injured (TBI) patients eligible for corticosteroid therapy for the prevention of HAP. METHODS This was a sub-study of the CORTI-TC trial, a multicenter, randomized, double-blind, controlled trial evaluating the risk of HAP at day 28 in 336 TBI patients treated or not with corticosteroid therapy. Patients were between 15 and 65 years with severe traumatic brain injury (Glasgow coma scale score ≤ 8 and trauma-associated lesion on brain CT scan) and were enrolled within 24 h of trauma. The blood levels of CRP and cortisoltotal&free, as a surrogate marker of the pro/anti-inflammatory response balance, were measured in samples collected before the treatment initiation. Endpoint was HAP on day 28. RESULTS Of the 179 patients with available samples, 89 (49.7%) developed an HAP. Cortisoltotal&free and CRP blood levels upon ICU admission were not significantly different between patients with or without HAP. The cortisoltotal/CRP ratio upon admission was 2.30 [1.25-3.91] in patients without HAP and 3.36 [1.74-5.09] in patients with HAP (p = 0.021). In multivariate analysis, a cortisoltotal/CRP ratio > 3, selected upon the best Youden index on the ROC curve, was independently associated with HAP (OR 2.50, CI95% [1.34-4.64] p = 0.004). The HR for HAP with corticosteroid treatment was 0.59 (CI95% [0.34-1.00], p = 0.005) in patients with a cortisoltotal/CRP ratio > 3, and 0.89 (CI95% [0.49-1.64], p = 0.85) in patients with a ratio < 3. CONCLUSION A cortisoltotal/CRP ratio > 3 upon admission may predict the development of HAP in severe TBI. Among these patients, corticosteroids reduce the occurrence HAP. We suggest that this ratio may select the patients who may benefit from corticosteroid therapy for the prevention of HAP.
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Affiliation(s)
- Marwan Bouras
- Surgical Intensive Care Unit, Hotel-Dieu, University Hospital of Nantes, 44093, Nantes, France
- EA3826 Therapeutiques Anti-Infectieuses, Institut de Recherche en Sante 2 Nantes Biotech, Medical University of Nantes, 44000, Nantes, France
| | - Antoine Roquilly
- Surgical Intensive Care Unit, Hotel-Dieu, University Hospital of Nantes, 44093, Nantes, France
- EA3826 Therapeutiques Anti-Infectieuses, Institut de Recherche en Sante 2 Nantes Biotech, Medical University of Nantes, 44000, Nantes, France
| | - Pierre-Joachim Mahé
- Surgical Intensive Care Unit, Hotel-Dieu, University Hospital of Nantes, 44093, Nantes, France
| | - Raphaël Cinotti
- Surgical Intensive Care Unit, Hotel-Dieu, University Hospital of Nantes, 44093, Nantes, France
| | - Mickaël Vourc'h
- Surgical Intensive Care Unit, Hotel-Dieu, University Hospital of Nantes, 44093, Nantes, France
- EA3826 Therapeutiques Anti-Infectieuses, Institut de Recherche en Sante 2 Nantes Biotech, Medical University of Nantes, 44000, Nantes, France
| | - Bastien Perrot
- UMR_S 1246 Methods in Patient-Centered Outcomes and Health Research, Nantes University, 44000, Nantes, France
| | - Kalyane Bach-Ngohou
- Biochemistry Laboratory, UMR INSERM 1235, University Hospital of Nantes, 44093, Nantes, France
| | - Damien Masson
- Biochemistry Laboratory, UMR INSERM 1235, University Hospital of Nantes, 44093, Nantes, France
| | - Karim Asehnoune
- Surgical Intensive Care Unit, Hotel-Dieu, University Hospital of Nantes, 44093, Nantes, France.
- EA3826 Therapeutiques Anti-Infectieuses, Institut de Recherche en Sante 2 Nantes Biotech, Medical University of Nantes, 44000, Nantes, France.
- Department of Anesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, 1 place Alexis Ricordeau, 44093, Nantes Cedex 9, France.
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Lorente L, Martín MM, Abreu-González P, Ramos L, Cáceres JJ, Argueso M, Solé-Violán J, Jiménez A, García-Marín V. Maintained high sustained serum malondialdehyde levels after severe brain trauma injury in non-survivor patients. BMC Res Notes 2019; 12:789. [PMID: 31796118 PMCID: PMC6892146 DOI: 10.1186/s13104-019-4828-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 11/26/2019] [Indexed: 12/19/2022] Open
Abstract
Objective Higher blood malondialdehyde (biomarker of lipid peroxidation) levels in the first hours of traumatic brain injury (TBI) have been found in patients with a worst prognosis. The objective of this study was to determine whether serum malondialdehyde levels during the first week of severe TBI could be used as mortality biomarkers. This was a multicenter, prospective and observational study performed in six Spanish Intensive Care Units. We included patients with severe TBI (defined as Glasgow Coma Scale < 9), and with Injury Severity Score in non-cranial aspects < 9. We determined serum malondialdehyde concentrations at days 1, 4 and 8 of TBI. We stablished 30-day mortality as the end-point study. Results We found that serum malondialdehyde concentrations at days 1 (p < 0.001), 4 (p < 0.001), and 8 (p < 0.001) of TBI were higher in non-survivor (n = 34) than in survivor (n = 90) patients. We found an area under curve of serum malondialdehyde concentrations at days 1, 4, and 8 of TBI to predict 30-day mortality of 77% (p < 0.001), 87% (p < 0.001) and 84% (p < 0.001) respectively. Thus, the new and most relevant findings of our study were serum malondialdehyde levels during the first week of TBI could be used as mortality biomarkers.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain.
| | - María M Martín
- Intensive Care Unit, Hospital Universitario Nuestra Señora de Candelaria, Crta del Rosario s/n, 38010, Santa Cruz de Tenerife, Spain
| | - Pedro Abreu-González
- Deparment of Phisiology, Faculty of Medicine, University of the La Laguna, Santa Cruz de Tenerife, Spain
| | - Luis Ramos
- Intensive Care Unit, Hospital General La Palma, Buenavista de Arriba s/n, Breña Alta, 38713, La Palma, Spain
| | - Juan J Cáceres
- Intensive Care Unit, Hospital Insular, Plaza Dr. Pasteur s/n, 35016, Las Palmas de Gran Canaria, Spain
| | - Mónica Argueso
- Intensive Care Unit, Hospital Clínico Universitario de Valencia, Avda Blasco Ibáñez nº17-19, 46004, Valencia, Spain
| | - Jordi Solé-Violán
- Intensive Care Unit, Hospital Universitario Dr. Negrín, CIBERES, Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Alejandro Jiménez
- Research Unit, Hospital Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain
| | - Victor García-Marín
- Deparment of Neurosurgery Hospital, Universitario de Canarias, Ofra, s/n. La Laguna, 38320, Santa Cruz de Tenerife, Spain
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Gibbons PW, Goldberg RJ, Muehlschlegel S. A pilot study evaluating a simple cardiac dysfunction score to predict complications and survival among critically-ill patients with traumatic brain injury. J Crit Care 2019; 54:130-135. [PMID: 31446230 PMCID: PMC6901741 DOI: 10.1016/j.jcrc.2019.08.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/22/2019] [Accepted: 08/06/2019] [Indexed: 01/29/2023]
Abstract
PURPOSE To describe the frequency of cardiovascular complications and cardiac dysfunction in critically-ill patients with moderate-severe traumatic brain injury (msTBI) and cardiac factors associated with in-hospital survival. METHODS Retrospective analysis of a prospective cohort study at a single Level-1 trauma center with a dedicated neuro-trauma intensive care unit (ICU). Adult patients admitted to the ICU with msTBI were consecutively enrolled in the prospective OPTIMISM study between November 2009 and January 2017. Cardiac dysfunction was measured using a combination of EKG parameters, echocardiography abnormalities, and peak serum troponin-I levels during the index hospitalization. These items were combined into a cardiac dysfunction index (CDI), ranging from 0 to 3 points and modeled in a Cox regression analysis. RESULTS A total of 326 patients with msTBI were included. For every one-point increase in the CDI, the multivariable adjusted risk of dying during the patient's acute hospitalization more than doubled (adjusted HR 2.41; 95% CI 1.29-4.53). CONCLUSION Cardiac dysfunction was common in patients with msTBI and independently associated with more severe brain injury and a reduction in hospital survival in this population. Further research is needed to validate the CDI and create more precise scoring tools.
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Affiliation(s)
| | - Robert J Goldberg
- University of Massachusetts Medical School, Worcester, USA; Department of Quantitative Health Sciences (Division of Epidemiology of Chronic Diseases and Vulnerable Populations), USA
| | - Susanne Muehlschlegel
- University of Massachusetts Medical School, Worcester, USA; Departments of Neurology (Neurocritical Care), Anesthesia/Critical Care and Surgery, USA
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Raj R, Luostarinen T, Pursiainen E, Posti JP, Takala RSK, Bendel S, Konttila T, Korja M. Machine learning-based dynamic mortality prediction after traumatic brain injury. Sci Rep 2019; 9:17672. [PMID: 31776366 PMCID: PMC6881446 DOI: 10.1038/s41598-019-53889-6] [Citation(s) in RCA: 75] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 11/07/2019] [Indexed: 12/21/2022] Open
Abstract
Our aim was to create simple and largely scalable machine learning-based algorithms that could predict mortality in a real-time fashion during intensive care after traumatic brain injury. We performed an observational multicenter study including adult TBI patients that were monitored for intracranial pressure (ICP) for at least 24 h in three ICUs. We used machine learning-based logistic regression modeling to create two algorithms (based on ICP, mean arterial pressure [MAP], cerebral perfusion pressure [CPP] and Glasgow Coma Scale [GCS]) to predict 30-day mortality. We used a stratified cross-validation technique for internal validation. Of 472 included patients, 92 patients (19%) died within 30 days. Following cross-validation, the ICP-MAP-CPP algorithm's area under the receiver operating characteristic curve (AUC) increased from 0.67 (95% confidence interval [CI] 0.60-0.74) on day 1 to 0.81 (95% CI 0.75-0.87) on day 5. The ICP-MAP-CPP-GCS algorithm's AUC increased from 0.72 (95% CI 0.64-0.78) on day 1 to 0.84 (95% CI 0.78-0.90) on day 5. Algorithm misclassification was seen among patients undergoing decompressive craniectomy. In conclusion, we present a new concept of dynamic prognostication for patients with TBI treated in the ICU. Our simple algorithms, based on only three and four main variables, discriminated between survivors and non-survivors with accuracies up to 81% and 84%. These open-sourced simple algorithms can likely be further developed, also in low and middle-income countries.
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Affiliation(s)
- Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029 HUS, Helsinki, Finland.
| | - Teemu Luostarinen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029 HUS, Helsinki, Finland
| | - Eetu Pursiainen
- Data Scientist, Analytics and AI Development Services, HUS IT Management, Helsinki University Hospital, Haartmaninkatu 4, PB 340, 00029 HUS, Helsinki, Finland
| | - Jussi P Posti
- Division of Clinical Neurosciences, Department of Neurosurgery, and Turku Brain Injury Centre, Turku University Hospital and University of Turku, Hämeentie 11, 20521, Turku, Finland
| | - Riikka S K Takala
- Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Hämeentie 11, 20521, Turku, Finland
| | - Stepani Bendel
- Division of Intensive Care, Department of Anesthesiology, Intensive Care and Pain Medicine, Kuopio University Hospital, Puijonlaaksontie 2, 70210, Kuopio, Finland
| | - Teijo Konttila
- Data Scientist, Analytics and AI Development Services, HUS IT Management, Helsinki University Hospital, Haartmaninkatu 4, PB 340, 00029 HUS, Helsinki, Finland
| | - Miikka Korja
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Topeliuksenkatu 5, PB 266, 00029 HUS, Helsinki, Finland
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Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol 2019; 10:1261. [PMID: 32038449 PMCID: PMC6988791 DOI: 10.3389/fneur.2019.01261] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 11/13/2019] [Indexed: 02/04/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Improved methods of monitoring real-time cerebral physiology are needed to better understand when secondary brain injury develops and what treatment strategies may alleviate or prevent such injury. In this review, we discuss emerging technologies that exist to better understand intracranial pressure (ICP), cerebral blood flow, metabolism, oxygenation and electrical activity. We also discuss approaches to integrating these data as part of a multimodality monitoring strategy to improve patient care.
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Affiliation(s)
- Brian Appavu
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - Brian T Burrows
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Stephen Foldes
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, AZ, United States.,Department of Child Health, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, United States
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Mikati AG, Flahive J, Khan MW, Vedantam A, Gopinath S, Nordness MF, Robertson C, Patel MB, Sheth KN, Muehlschlegel S. Multicenter Validation of the Survival After Acute Civilian Penetrating Brain Injuries (SPIN) Score. Neurosurgery 2019; 85:E872-E879. [PMID: 31065707 PMCID: PMC6904849 DOI: 10.1093/neuros/nyz127] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 03/28/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Civilian penetrating traumatic brain injury (pTBI) is a serious public health problem in the United States, but predictors of outcome remain largely understudied. We previously developed the Survival After Acute Civilian Penetrating Brain Injuries (SPIN) score, a logistic, regression-based risk stratification scale for estimating in-hospital and 6-mo survival after civilian pTBI with excellent discrimination (area under the receiver operating curve [AUC-ROC = 0.96]) and calibration, but it has not been validated. OBJECTIVE To validate the SPIN score in a multicenter cohort. METHODS We identified pTBI patients from 3 United States level-1 trauma centers. The SPIN score variables (motor Glasgow Coma Scale [mGCS], sex, admission pupillary reactivity, self-inflicted pTBI, transfer status, injury severity score, and admission international normalized ratio [INR]) were retrospectively collected from local trauma registries and chart review. Using the original SPIN score multivariable logistic regression model, AUC-ROC analysis and Hosmer-Lemeshow goodness of fit testing were performed to determine discrimination and calibration. RESULTS Of 362 pTBI patients available for analysis, 105 patients were lacking INR, leaving 257 patients for the full SPIN model validation. Discrimination (AUC-ROC = 0.88) and calibration (Hosmer-Lemeshow goodness of fit, P value = .58) were excellent. In a post hoc sensitivity analysis, we removed INR from the SPIN model to include all 362 patients (SPINNo-INR), still resulting in very good discrimination (AUC-ROC = 0.82), but reduced calibration (Hosmer-Lemeshow goodness of fit, P value = .04). CONCLUSION This multicenter pTBI study confirmed that the full SPIN score predicts survival after civilian pTBI with excellent discrimination and calibration. Admission INR significantly adds to the prediction model discrimination and should be routinely measured in pTBI patients.
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Affiliation(s)
- Abdul Ghani Mikati
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Julie Flahive
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Muhammad W Khan
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Aditya Vedantam
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Shankar Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Mina F Nordness
- Center for Trauma, Burn, and Emergency Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center; Vanderbilt University Medical Center, Nashville, Tennessee
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Mayur B Patel
- Center for Trauma, Burn, and Emergency Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
- Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center; Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin N Sheth
- Neurocritical Care and Emergency Neurology Division, Department of Neurology, Yale University, New Haven, Connecticut
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Susanne Muehlschlegel
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts
- Department of Anesthesia/Critical Care and Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
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High Serum Caspase-Cleaved Cytokeratin-18 Levels and Mortality of Traumatic Brain Injury Patients. Brain Sci 2019; 9:brainsci9100269. [PMID: 31658711 PMCID: PMC6826452 DOI: 10.3390/brainsci9100269] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 10/09/2019] [Accepted: 10/09/2019] [Indexed: 01/28/2023] Open
Abstract
Objective: Apoptosis increases in traumatic brain injury (TBI). Caspase-cleaved cytokeratin (CCCK)-18 in blood during apoptosis could appear. At the time of admission due to TBI, higher blood CCCK-18 levels were found in non-surviving than in surviving patients. Therefore, the objective of our study was to analyze whether serum CCCK-18 levels determined during the first week after TBI could predict early mortality (at 30 days). Methods: Severe TBI patients were included (considering severe when Glasgow Coma Scale < 9) in this observational and multicentre study. Serum CCCK-18 levels were determined at day 1 of TBI, and at days 4 and 8 after TBI. Results: Serum CCCK-18 levels at day 1 of TBI, and in the days 4 and 8 after TBI were higher (p < 0.001) in non-surviving than in surviving patients (34 and 90 patients, respectively) and could predict early mortality (p < 0.001 in the area under the curve). Conclusions: The new findings from our study were that serum CCCK-18 levels at any moment of the first week of TBI were higher in non-surviving patients and were able to predict early mortality.
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