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Kambara M, Ikawa F, Hidaka T, Yamamori Y, Yamamoto Y, Michihata N, Uchimura M, Yoshikane T, Akiyama Y, Horie N, Hayashi K. Lack of Association of Chronological Age and Antithrombotic Agents With Acute Intracranial Hemorrhage in the Group of Older Adults With Traumatic Brain Injury. Neurosurgery 2025; 96:1321-1332. [PMID: 39440941 DOI: 10.1227/neu.0000000000003240] [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: 12/25/2023] [Accepted: 09/06/2024] [Indexed: 10/25/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Some reports suggest that older patients with traumatic brain injury (TBI) are more likely to experience acute intracranial hemorrhage, resulting in poor outcomes. However, the association between precise chronological age and use of antithrombotic agents with acute intracranial hemorrhage in these patients remains unknown. The aim of this study was to determine factors associated with acute intracranial hemorrhage and poor outcomes in patients with TBI, including chronological age and use of antithrombotic agents. METHODS Patients hospitalized for TBI between January 2006 and December 2021 were included. Patients were categorized by age groups of <65 years, 65 to 74 years, 75 to 84 years, and ≥85 years. Associations between each age group and acute intracranial hemorrhage, a poor outcome at discharge, and in-hospital mortality were evaluated. RESULTS The cohort included 1086 patients, with 713 (65.7%) in the ≥65 age group. Although chronological age was associated with acute intracranial hemorrhage in patients aged <65 years (odds ratio [OR] 1.02; 95% CI 1.01-1.03), it was not associated with patients aged ≥65 years. None of the antithrombotic agents investigated were associated with acute intracranial hemorrhage in the group aged ≥65 years. Although chronological age was associated with a poor outcome in patients aged <65 years (OR 1.03; 95% CI 1.01-1.07), it was not associated in those aged ≥65 years. The ≥85 year age group (OR 2.30; 95% CI 1.18-4.51) compared with <65 years were significantly associated with a poor outcome. None of the antithrombotic agents investigated were associated with a poor outcome in the group aged ≥65 years. CONCLUSION Our findings confirmed the lack of an association of chronological age and antithrombotic agents with acute intracranial hemorrhage in the group of older adults with TBI. Our findings suggest that antithrombotic agents may be safely used, even in older adults.
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Affiliation(s)
- Mizuki Kambara
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo , Shimane , Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo , Shimane , Japan
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo , Shimane , Japan
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima , Japan
| | - Toshikazu Hidaka
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo , Shimane , Japan
| | - Yuji Yamamori
- Department of Emergency and Critical Care Medicine, Shimane Prefectural Central Hospital, Izumo , Shimane , Japan
| | - Yoshiaki Yamamoto
- Department of Rehabilitation, Shimane Prefectural Central Hospital, Izumo , Shimane , Japan
| | - Nobuaki Michihata
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Bunkyo , Tokyo , Japan
| | - Masahiro Uchimura
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo , Shimane , Japan
| | - Tsutomu Yoshikane
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo , Shimane , Japan
| | - Yasuhiko Akiyama
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo , Shimane , Japan
- Department of Neurosurgery, Sakurakai Hospital, Osakasayama , Osaka , Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima , Japan
| | - Kentaro Hayashi
- Department of Neurosurgery, Shimane University Faculty of Medicine, Izumo , Shimane , Japan
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Eric Nyam TT, Tu KC, Kuo YH, Wang CC, Liu CF, Liao JC, Kuo CL. Age and pupil size: key predictors of mortality in traumatic brain injury patients with GCS 3. Front Neurol 2025; 16:1536421. [PMID: 40255893 PMCID: PMC12006044 DOI: 10.3389/fneur.2025.1536421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2024] [Accepted: 03/26/2025] [Indexed: 04/22/2025] Open
Abstract
This study investigates the relationship between mortality and specific clinical factors in patients with severe traumatic brain injury (TBI) who present with a Glasgow Coma Scale (GCS) score of 3. Data from 161 adult patients were collected from the Chi-Mei Medical Center in Taiwan, spanning 2010 to 2019. The findings revealed an overall mortality rate of 44.10%, with significant predictors of mortality identified as age and pupil size. The Spearman correlation analysis showed that both age and pupil sizes were positively correlated with mortality rates. Multiple logistic regression confirmed age and left pupil size as strong predictors of mortality. Patients with GCS 3 and both unreactive pupils measuring 4 mm or more experienced the highest mortality rate of 68.39%, while those with pupils less than 4 mm had a lower mortality rate of 32.26%. The study determined optimal cut-off values for age and pupil size using ROC and AUC analysis, highlighting the significance of age in mortality predictions. These findings underscore the critical role of age and pupil size in the prognosis of TBI patients and provide valuable guidance for clinicians managing such cases.
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Affiliation(s)
| | - Kuan-Chi Tu
- Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Yun-Hsuan Kuo
- Department of Clinical Psychology, Chung Shan Medical University, Taichung, Taiwan
| | - Che-Chuan Wang
- Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Chung-Feng Liu
- Department of Medical Research, Chi Mei Medical Center, Tainan, Taiwan
| | - Jen-Chieh Liao
- Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan
| | - Ching-Lung Kuo
- Department of Neurosurgery, Chi Mei Medical Center, Tainan, Taiwan
- Department of Clinical Psychology, Chung Shan Medical University, Taichung, Taiwan
- School of Medicine, College of Medicine, National Sun Yat-Sen University, Kaohsiung, Taiwan
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Ferreira FM, Lino BT, Giannetti AV. Ultrasonographic evaluation of optic nerve sheath diameter in patients severe traumatic brain injury: a comparison with intraparenchymal pressure monitoring. Neurosurg Rev 2025; 48:47. [PMID: 39810071 DOI: 10.1007/s10143-025-03202-z] [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: 08/13/2024] [Revised: 11/27/2024] [Accepted: 01/04/2025] [Indexed: 01/16/2025]
Abstract
OBJECTIVE Increased intracranial pressure (ICP) can worsen the clinical condition of traumatic brain injury (TBI) patients. One non-invasive and easily bedside-performed technique to estimate ICP is ultrasonographic measurement of optic nerve sheath diameter (ONSD). This study aimed to analyze ONSD and correlate it with ICP values obtained by intraparenchymal monitoring to establish the ONSD threshold value for elevated ICP and reference range of ONSD in severe TBI patients. METHODS Forty severe TBI patients (Glasgow Coma Scale Score ≤ 8) were included. Ultrasonographic measurement of ONSD was performed and compared with intraparenchymal ICP monitoring to assess their association and determine the ONSD threshold value. Exclusion criteria included individuals under eighteen years old, penetrating TBI, or direct ocular trauma. RESULTS Fifty-three ONSD measurements were conducted in all patients. The mean ONSD value in the group with intracranial pressure < 20 mmHg was 5.4 mm ± 1.0, while in the group with intracranial pressure ≥ 20 mmHg, it was 6.4 mm ± 0.7 (p = 0.0026). A positive and statistically significant correlation, albeit weak (r = 0.33), was observed between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring. The statistical analysis of the ROC curve identified the best cut-off as 6.18 mm, with 77.8% sensitivity and 81.8% specificity. CONCLUSION Our results reveal a positive, albeit weak, correlation between ultrasonographic measurement of ONSD and intraparenchymal ICP monitoring, with an ONSD threshold value of 6.18 mm. Achieving only 77.8% sensitivity and considering the substantial variability between ONSD measurements (standard deviation at 1.0) might limit the reliability of ICP assessment based solely on ONSD measurements.
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Affiliation(s)
- Felipe M Ferreira
- Department of Surgery, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Breno T Lino
- Department of Ophthalmology, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Alexandre V Giannetti
- Department of Surgery, School of Medicine, Federal University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil.
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Nyam TTE, Tu KC, Chen NC, Wang CC, Liu CF, Kuo CL, Liao JC. Predictive Modeling of Long-Term Care Needs in Traumatic Brain Injury Patients Using Machine Learning. Diagnostics (Basel) 2024; 15:20. [PMID: 39795548 PMCID: PMC11720696 DOI: 10.3390/diagnostics15010020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2024] [Revised: 12/19/2024] [Accepted: 12/21/2024] [Indexed: 01/13/2025] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) research often focuses on mortality rates or functional recovery, yet the critical need for long-term care among patients dependent on institutional or Respiratory Care Ward (RCW) support remains underexplored. This study aims to address this gap by employing machine learning techniques to develop and validate predictive models that analyze the prognosis of this patient population. METHOD Retrospective data from electronic medical records at Chi Mei Medical Center, encompassing 2020 TBI patients admitted to the ICU between January 2016 and December 2021, were collected. A total of 44 features were included, utilizing four machine learning models and various feature combinations based on clinical significance and Spearman correlation coefficients. Predictive performance was evaluated using the area under the curve (AUC) of the receiver operating characteristic (ROC) curve and validated with the DeLong test and SHAP (SHapley Additive exPlanations) analysis. RESULT Notably, 236 patients (11.68%) were transferred to long-term care centers. XGBoost with 27 features achieved the highest AUC (0.823), followed by Random Forest with 11 features (0.817), and LightGBM with 44 features (0.813). The DeLong test revealed no significant differences among the best predictive models under various feature combinations. SHAP analysis illustrated a similar distribution of feature importance for the top 11 features in XGBoost, with 27 features, and Random Forest with 11 features. CONCLUSIONS Random Forest, with an 11-feature combination, provided clinically meaningful predictive capability, offering early insights into long-term care trends for TBI patients. This model supports proactive planning for institutional or RCW resources, addressing a critical yet often overlooked aspect of TBI care.
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Affiliation(s)
- Tee-Tau Eric Nyam
- Department of Neurosurgery, Chi Mei Medical Center, Tainan 711, Taiwan; (T.-T.E.N.); (K.-C.T.); (C.-C.W.)
- Center of General Education, Chia Nan University of Phamacy and Science, Tainan 717, Taiwan
| | - Kuan-Chi Tu
- Department of Neurosurgery, Chi Mei Medical Center, Tainan 711, Taiwan; (T.-T.E.N.); (K.-C.T.); (C.-C.W.)
| | - Nai-Ching Chen
- Department of Nursing, Chi Mei Medical Center, Tainan 711, Taiwan;
| | - Che-Chuan Wang
- Department of Neurosurgery, Chi Mei Medical Center, Tainan 711, Taiwan; (T.-T.E.N.); (K.-C.T.); (C.-C.W.)
| | - Chung-Feng Liu
- Department of Medical Research, Chi Mei Medical Center, Tainan 711, Taiwan;
| | - Ching-Lung Kuo
- Department of Neurosurgery, Chi Mei Medical Center, Tainan 711, Taiwan; (T.-T.E.N.); (K.-C.T.); (C.-C.W.)
- Department of Nursing, Chi Mei Medical Center, Tainan 711, Taiwan;
- College of Medicine, National Sun-Yat-Sen University, Kaohsiung 805, Taiwan
| | - Jen-Chieh Liao
- Department of Neurosurgery, ChiaLi Chi Mei Medical Hospital, Tainan 722, Taiwan
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Godoy DA, Rubiano AM, Aguilera S, Jibaja M, Videtta W, Rovegno M, Paranhos J, Paranhos E, de Amorim RLO, Castro Monteiro da Silva Filho R, Paiva W, Flecha J, Faleiro RM, Almanza D, Rodriguez E, Carrizosa J, Hawryluk GWJ, Rabinstein AA. Moderate Traumatic Brain Injury in Adult Population: The Latin American Brain Injury Consortium Consensus for Definition and Categorization. Neurosurgery 2024; 95:e57-e70. [PMID: 38529956 DOI: 10.1227/neu.0000000000002912] [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: 07/13/2023] [Accepted: 01/30/2024] [Indexed: 03/27/2024] Open
Abstract
Moderate traumatic brain injury (TBI) is a diagnosis that describes diverse patients with heterogeneity of primary injuries. Defined by a Glasgow Coma Scale between 9 and 12, this category includes patients who may neurologically worsen and require increasing intensive care resources and/or emergency neurosurgery. Despite the unique characteristics of these patients, there have not been specific guidelines published before this effort to support decision-making in these patients. A Delphi consensus group from the Latin American Brain Injury Consortium was established to generate recommendations related to the definition and categorization of moderate TBI. Before an in-person meeting, a systematic review of the literature was performed identifying evidence relevant to planned topics. Blinded voting assessed support for each recommendation. A priori the threshold for consensus was set at 80% agreement. Nine PICOT questions were generated by the panel, including definition, categorization, grouping, and diagnosis of moderate TBI. Here, we report the results of our work including relevant consensus statements and discussion for each question. Moderate TBI is an entity for which there is little published evidence available supporting definition, diagnosis, and management. Recommendations based on experts' opinion were informed by available evidence and aim to refine the definition and categorization of moderate TBI. Further studies evaluating the impact of these recommendations will be required.
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Affiliation(s)
| | - Andres M Rubiano
- Universidad El Bosque, Bogota , Colombia
- MEDITECH Foundation, Cali , Colombia
| | - Sergio Aguilera
- Department Neurosurgery, Herminda Martín Hospital, Chillan , Chile
| | - Manuel Jibaja
- School of Medicine, San Francisco University, Quito , Ecuador
- Intensive Care Unit, Eugenio Espejo Hospital, Quito , Ecuador
| | - Walter Videtta
- Intensive Care Unit, Hospital Posadas, Buenos Aires , Argentina
| | - Maximiliano Rovegno
- Department Critical Care, Pontificia Universidad Católica de Chile, Santiago , Chile
| | - Jorge Paranhos
- Department of Neurosurgery and Critical Care, Santa Casa da Misericordia, Sao Joao del Rei , Minas Gerais , Brazil
| | - Eduardo Paranhos
- Intensive Care Unit, HEMORIO and Santa Barbara Hospitals, Rio de Janeiro , Brazil
| | | | | | - Wellingson Paiva
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Sao Paulo , Brazil
| | - Jorge Flecha
- Intensive Care Unit, Trauma Hospital, Asuncion , Paraguay
- Social Security Institute Central Hospital, Asuncion , Paraguay
| | - Rodrigo Moreira Faleiro
- Department of Neurosurgery, João XXIII Hospital and Felício Rocho Hospital, Faculdade de Ciencias Médicas de MG, Belo Horizonte , Brazil
| | - David Almanza
- Critical and Intensive Care Medicine Department, University Hospital, Fundación Santa Fe de Bogotá, Bogotá , Colombia
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
| | - Eliana Rodriguez
- Critical and Intensive Care Medicine Department, University Hospital, Fundación Santa Fe de Bogotá, Bogotá , Colombia
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
| | - Jorge Carrizosa
- Universidad del Rosario, School of Medicine and Health Sciences, Bogotá , Colombia
- Neurointensive Care Unit, Hospital Universitario Fundación Santa Fe de Bogotá, Bogotá , Colombia
| | - Gregory W J Hawryluk
- Cleveland Clinic Akron General Hospital, Neurological Institute, Akron , Ohio , USA
| | - Alejandro A Rabinstein
- Neurocritical Care and Hospital Neurology Division, Mayo Clinic, Rochester , Minnesota , USA
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Grille P, Biestro A, Rekate HL. Intracranial Hypertension with Patent Basal Cisterns: Controlled Lumbar Drainage as a Therapeutic Option. Selected Case Series. Neurocrit Care 2024; 40:1070-1082. [PMID: 37936017 DOI: 10.1007/s12028-023-01878-z] [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: 02/21/2023] [Accepted: 10/06/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND There are pathological conditions in which intracranial hypertension and patent basal cisterns in computed tomography coexist. These situations are not well recognized, which could lead to diagnostic errors and improper management. METHODS We present a retrospective case series of patients with traumatic brain injury, subarachnoid hemorrhage, and cryptococcal meningitis who were treated at our intensive care unit. Criteria for deciding placement of an external lumbar drain were (1) intracranial hypertension refractory to osmotherapy, hyperventilation, neuromuscular blockade, intravenous anesthesia, and, in some cases, decompressive craniectomy and (2) a computed tomography scan that showed open basal cisterns and no mass lesion. RESULTS Eleven patients were studied. Six of the eleven patients treated with controlled lumbar drainage are discussed as illustrative cases. All patients developed intracranial hypertension refractory to maximum medical treatment, including decompressive craniectomy in Four of the eleven cases. Controlled external lumbar drainage led to immediate and sustained control of elevated intracranial pressure in all patients, with good neurological outcomes. No brain herniation, intracranial bleeding, or meningitis was detected during this procedure. CONCLUSIONS Our study provides preliminary evidence that in selected patients who develop refractory intracranial hypertension with patent basal cisterns and no focal mass effect on computed tomography, controlled lumbar drainage appears to be a therapeutic option. In our study there were no deaths or complications. Prospective and larger studies are needed to confirm our results.
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Affiliation(s)
- Pedro Grille
- Intensive Care Unit, Hospital Maciel, Administración de los Servicios de Salud del Estado (ASSE), 25 de Mayo 174, 11000, Montevideo, Uruguay.
| | - Alberto Biestro
- Intensive Care Unit, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Harold L Rekate
- Department of Neurosurgery, Hofstra University, Hempstead, NY, USA
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Fossi F, Robba C, Rota M, Vargiolu A, Lagravinese D, Volpi P, Citerio G. Intracranial pressure monitor insertion in traumatic brain injury: a single center, retrospective decision process analysis. J Neurosurg Sci 2024; 68:51-58. [PMID: 30421894 DOI: 10.23736/s0390-5616.18.04568-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evidence-based indications for intracranial pressure (ICP) monitoring in patients with traumatic brain injury (TBI) are lacking. The aim of this study was to analyze the main factors that guided the decision-making of invasive ICP monitoring in a large cohort of TBI patients from our institution. METHODS This is a retrospective, single centre, observational study including adult TBI patients consecutively admitted to our Neurointensive Care Unit over 20 years. Logistic regression analyses were performed to identify potential factors associated with the decision for ICP monitor insertion. A decision tree was developed to identify the combination of factors with the highest statistical power to predict the decision for ICP monitor insertion. RESULTS A total of 857 adult patients were included in the analysis. The decision to monitor ICP was strongly related to different factors, including Glasgow Coma Scale (GCS), computed tomography (CT) scan classification, pupils' reactivity, and patients' prognosis at the admission calculated by the International Mission on Prognosis in Traumatic Brain Injury (IMPACT) score (P<0.01). Results from the decision tree showed an overall ability of the 72% in the prediction of ICP monitoring and that, among the factors analyzed, CT findings had the primarily and strongest discrimination power. CONCLUSIONS The decision to insert an invasive ICP monitoring in patients with TBI is multifactorial. Among the different factors analysed in our cohort of TBI patients, prognostication factors as for IMPACT score and in particular CT findings could potentially explain the decision making for ICP monitoring.
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Affiliation(s)
- Francesca Fossi
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy -
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, IRCCS San Martino University Hospital, Genoa, Italy
| | - Matteo Rota
- Unit of Biostatistics and Bionformatics, Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Alessia Vargiolu
- Unit of Neurointensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Monza, Monza-Brianza, Italy
| | | | - Paola Volpi
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
- Unit of Neurointensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Monza, Monza-Brianza, Italy
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Zhang X, Sha Z, Gao C, Yuan J, He L, Huang J, Jiang R. Factors influencing wait-and-watch management in mild primary chronic subdural hematoma: a retrospective case-control study. Acta Neurol Belg 2023; 123:2277-2286. [PMID: 37269419 DOI: 10.1007/s13760-023-02293-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/15/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE To identify prognostic factors in patients with primary chronic subdural hematoma (CSDH) undergoing wait-and-watch management. METHODS A case-control study was conducted in a single center from February 2019 to November 2021 to identify independent influencing factors of wait-and-watch management in mild CSDH patients using wait-and-watch as monotherapy. A total of 39 patients who responded to wait-and-watch management (cases) and 24 nonresponders (controls) matched for age, sex, height, weight, MGS-GCS (Markwalder grading scale and Glasgow Coma Scale), and bilateral hematoma were included. Demographics, blood cell counts, serum biochemical levels, imaging data, and relevant clinical features at baseline were collected. RESULTS Univariate analysis revealed significant differences between cases and controls in hematoma volume, ability to urinate, maximal thickness of the hematoma, and hypodensity of the hematoma. Hypodense hematoma and hematoma volume were independently associated with the outcome in multivariate analysis. Combining these independently influencing factors revealed an area under the receiver operator characteristic curve of 0.741 (95% CI 0.609-0.874, sensitivity = 0.783, specificity = 0.667). CONCLUSIONS The results of this study may aid in identifying patients with mild primary CSDH who could benefit from conservative management. While wait-and-watch management may be an option in some cases, clinicians need to suggest medical interventions, such as pharmacotherapy, when appropriate.
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Affiliation(s)
- Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China
| | - Lei He
- Department of Neurology, Chengde Central Hospital, Chengde, 067000, Hebei, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China.
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
- Ministry of Education, Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Tianjin, China.
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9
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Frontera JA, Fang T, Grayson K, Lalchan R, Dickstein L, Hussain MS, Kahn DE, Lord AS, Mazzuchin D, Melmed KR, Rutledge C, Zhou T, Lewis A. Poor Accuracy of Manually Derived Head Computed Tomography Parameters in Predicting Intracranial Hypertension After Nontraumatic Intracranial Hemorrhage. Neurocrit Care 2023; 39:677-689. [PMID: 36577900 DOI: 10.1007/s12028-022-01662-5] [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: 09/20/2022] [Accepted: 12/08/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND The utility of head computed tomography (CT) in predicting elevated intracranial pressure (ICP) is known to be limited in traumatic brain injury; however, few data exist in patients with spontaneous intracranial hemorrhage. METHODS We conducted a retrospective review of prospectively collected data in patients with nontraumatic intracranial hemorrhage (subarachnoid hemorrhage [SAH] or intraparenchymal hemorrhage [IPH]) who underwent external ventricular drain (EVD) placement. Head CT scans performed immediately prior to EVD placement were quantitatively reviewed for features suggestive of elevated ICP, including temporal horn diameter, bicaudate index, basal cistern effacement, midline shift, and global cerebral edema. The modified Fisher score (mFS), intraventricular hemorrhage score, and IPH volume were also measured, as applicable. We calculated the accuracy, positive predictive value (PPV), and negative predictive value (NPV) of these radiographic features for the coprimary outcomes of elevated ICP (> 20 mm Hg) at the time of EVD placement and at any time during the hospital stay. Multivariable backward stepwise logistic regression analysis was performed to identify significant radiographic factors associated with elevated ICP. RESULTS Of 608 patients with intracranial hemorrhages enrolled during the study time frame, 243 (40%) received an EVD and 165 (n = 107 SAH, n = 58 IPH) had a preplacement head CT scan available for rating. Elevated opening pressure and elevated ICP during hospitalization were recorded in 48 of 152 (29%) and 103 of 165 (62%), respectively. The presence of ≥ 1 radiographic feature had only 32% accuracy for identifying elevated opening pressure (PPV 30%, NPV 58%, area under the curve [AUC] 0.537, 95% asymptotic confidence interval [CI] 0.436-0.637, P = 0.466) and 59% accuracy for predicting elevated ICP during hospitalization (PPV 63%, NPV 40%, AUC 0.514, 95% asymptotic CI 0.391-0.638, P = 0.820). There was no significant association between the number of radiographic features and ICP elevation. Head CT scans without any features suggestive of elevated ICP occurred in 25 of 165 (15%) patients. However, 10 of 25 (40%) of these patients had elevated opening pressure, and 15 of 25 (60%) had elevated ICP during their hospital stay. In multivariable models, mFS (adjusted odds ratio [aOR] 1.36, 95% CI 1.10-1.68) and global cerebral edema (aOR 2.93, 95% CI 1.27-6.75) were significantly associated with elevated ICP; however, their accuracies were only 69% and 60%, respectively. All other individual radiographic features had accuracies between 38 and 58% for identifying intracranial hypertension. CONCLUSIONS More than 50% of patients with spontaneous intracranial hemorrhage without radiographic features suggestive of elevated ICP actually had ICP > 20 mm Hg during EVD placement or their hospital stay. Morphological head CT findings were only 32% and 59% accurate in identifying elevated opening pressure and ICP elevation during hospitalization, respectively.
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Affiliation(s)
- Jennifer A Frontera
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA.
- Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY, USA.
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Taolin Fang
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Kammi Grayson
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Rebecca Lalchan
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Leah Dickstein
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - M Shazam Hussain
- Cerebrovascular Center of the Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - D Ethan Kahn
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Aaron S Lord
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Daniel Mazzuchin
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Kara R Melmed
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Caleb Rutledge
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
| | - Ting Zhou
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
| | - Ariane Lewis
- Department of Neurology, New York University School of Medicine, 150 55th St., Brooklyn, New York, NY, USA
- Department of Neurosurgery, New York University School of Medicine, New York, NY, USA
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10
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Maramattom BV, Abraham M, Sundararajan A. Assessment of Midline Shift in Postdecompressive Craniectomy Patients in Neurocritical Care: Comparison between Transcranial Ultrasonography and Computerized Tomography. Neurol India 2023; 71:1167-1171. [PMID: 38174452 DOI: 10.4103/0028-3886.391386] [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] [Indexed: 01/05/2024]
Abstract
Background Monitoring and evaluation of intracranial structures remain a fundamental element in the neurointensive care unit. Most used technique to monitor progression is the use of computed tomography (CT) in intracranial hemorrhage (ICH) or stroke. Rapid assessment of brain pathology can be made using CT to analyze the midline shift (MLS), hematoma expansion, and ventricular size, but transferring a patient who is intubated is time and resource-consuming task. Ultrasonography is a noninvasive technique, portable, and has the possibility of fast interpretation. Aims and Objectives To measure the brain MLS in decompressive craniectomy patients using transcranial ultrasonography (TCS) and compare the correlation of these results with CT scan measurements of MLS in the same patient. Materials and Methods Patients who have undergone decompressive craniectomy due to various reasons like ICH, traumatic brain injury, etc., and have a MLS. Trans cranial ultrasonography was assessed by a single consultant (Neuro Critical Care Intensivist) who was blinded for the CT scan measurement. CT scan measurement of MLS was assessed by a neuroradiologist using standard guidelines, who was blinded for the TCS results of MLS. The finding of a MLS >0.5 cm in the CT scan was considered a significant MLS. Results A total of 31 patients were recruited for the study. MLS measured using CT was 0.91 ± 0.67 cm. MLS via TCS was 0.91 ± 0.66 cm. A significant MLS via TCS was found in 77.4%. Intraclass correlation coefficient (ICC) was calculated between CT-MLS and TCS MLS and obtained the value of ICC as 0.996, indicating an almost perfect agreement. Conclusion Patients after decompressive craniectomy may present as an ideal candidate to visualize intracerebral anatomy with a high resolution. TCS might be considered as an alternative to CT to measure MLS in decompressive craniectomy patients.
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Affiliation(s)
- Boby V Maramattom
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
| | - Mathew Abraham
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
| | - Ananthram Sundararajan
- Department of Neurology, Division of Neurocritical Care, Aster Medcity, Kochi, Kerala, India
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11
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Riordan K, Mamaril-Davis J, Aguilar-Salinas P, Dumont TM, Weinand ME. Outcomes following therapeutic intervention of post-traumatic vasospasm: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 232:107877. [PMID: 37441930 DOI: 10.1016/j.clineuro.2023.107877] [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: 04/06/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Vasospasm occurrence following traumatic brain injury may impact neurologic and functional recovery of patients, yet treatment of post-traumatic vasospasm (PTV) has not been well documented. This systematic review and meta-analysis aims to assess the current evidence regarding favorable outcome as measured by Glasgow Outcome Scale (GOS) scores following treatment of PTV. METHODS A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality; occurrence of PTV; rate of favorable outcome following each treatment modality; and follow-up duration. Treatments evaluated were calcium channel blockers (CCBs), endovascular intervention, and dopamine-induced hypertension. Outcomes were compared via the random-effects analysis. RESULTS Fourteen studies with 1885 PTV patients were quantitatively analyzed: 982 patients who received tailored therapeutic intervention and 903 patients who did not receive tailored therapy. For patients undergoing treatment, the rate of favorable outcome was 57.3 % (500/872 patients; 95 % CI 54.1 - 60.6 %) following administration of CCBs, 94.1 % (16/17 patients; 95 % CI 82.9 - 100.0 %) following endovascular intervention, and 54.8 % (51/93 patients; 95 % CI 44.7 - 65.0 %) following dopamine-induced hypertension. Of note, the endovascular group had the highest rate of favorable outcome but was also the smallest sample size (n = 17). Patients who received tailored therapeutic intervention for PTV had a higher rate of favorable outcome than patients who did not receive tailored therapy: 57.7 % (567/982 patients; 95 % CI 54.1 - 60.8 %) versus 52.0 % (470/903 patients; 95 % CI 48.8 - 55.3 %), respectively. CONCLUSIONS The available data suggests that tailored therapeutic intervention of PTV results in a favorable outcome. While endovascular intervention of PTV had the highest rate of favorable outcome, both CCB administration and dopamine-induced hypertension had similar lower rates of favorable outcome.
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Affiliation(s)
- Katherine Riordan
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - James Mamaril-Davis
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Travis M Dumont
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Martin E Weinand
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States.
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12
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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Zeiler FA. Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives. Neurotrauma Rep 2023; 4:478-494. [PMID: 37636334 PMCID: PMC10457629 DOI: 10.1089/neur.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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13
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Sarker P, Ong J, Zaman N, Kamran SA, Waisberg E, Paladugu P, Lee AG, Tavakkoli A. Extended reality quantification of pupil reactivity as a non-invasive assessment for the pathogenesis of spaceflight associated neuro-ocular syndrome: A technology validation study for astronaut health. LIFE SCIENCES IN SPACE RESEARCH 2023; 38:79-86. [PMID: 37481311 DOI: 10.1016/j.lssr.2023.06.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 05/26/2023] [Accepted: 06/01/2023] [Indexed: 07/24/2023]
Abstract
The National Aeronautics and Space Administration (NASA) has rigorously documented a group of neuro-ophthalmic findings in astronauts during and after long-duration spaceflight known as spaceflight associated neuro-ocular syndrome (SANS). For astronaut safety and mission effectiveness, understanding SANS and countermeasure development are of utmost importance. Although the pathogenesis of SANS is not well defined, a leading hypothesis is that SANS might relate to a sub-clinical increased intracranial pressure (ICP) from cephalad fluid shifts in microgravity. However, no direct ICP measurements are available during spaceflight. To further understand the role of ICP in SANS, pupillometry can serve as a promising non-invasive biomarker for spaceflight environment as ICP is correlated with the pupil variables under illumination. Extended reality (XR) can help to address certain limitations in current methods for efficient pupil testing during spaceflight. We designed a protocol to quantify parameters of pupil reactivity in XR with an equivalent time duration of illumination on each eye compared to pre-existing, non-XR methods. Throughout the assessment, the pupil diameter data was collected using HTC Vive Pro-VR headset, thanks to its eye-tracking capabilities. Finally, the data was used to compute several pupil variables. We applied our methods to 36 control subjects. Pupil variables such as maximum and minimum pupil size, constriction amplitude, average constriction amplitude, maximum constriction velocity, latency and dilation velocity were computed for each control data. We compared our methods of calculation of pupil variables with the non-XR methods existing in the literature. Distributions of the pupil variables such as latency, constriction amplitude, and velocity of 36 control data displayed near-identical results from the non-XR literature for normal subjects. We propose a new method to evaluate pupil reactivity with XR technology to further understand ICP's role in SANS and provide further insight into SANS countermeasure development for future spaceflight.
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Affiliation(s)
- Prithul Sarker
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Nevada, United States
| | - Joshua Ong
- Michigan Medicine, University of Michigan, Ann Arbor, Michigan, United States
| | - Nasif Zaman
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Nevada, United States
| | - Sharif Amit Kamran
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Nevada, United States
| | - Ethan Waisberg
- University College Dublin School of Medicine, Belfield, Dublin, Ireland
| | - Phani Paladugu
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States; Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, United States
| | - Andrew G Lee
- Center for Space Medicine, Baylor College of Medicine, Houston, Texas, United States; Department of Ophthalmology, Blanton Eye Institute, Houston Methodist Hospital, Houston, Texas, United States; The Houston Methodist Research Institute, Houston Methodist Hospital, Houston, Texas, United States; Departments of Ophthalmology, Neurology, and Neurosurgery, Weill Cornell Medicine, New York, New York, United States; Department of Ophthalmology, University of Texas Medical Branch, Galveston, Texas, United States; University of Texas MD Anderson Cancer Center, Houston, Texas, United States; Texas A&M College of Medicine, Texas, United States; Department of Ophthalmology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Alireza Tavakkoli
- Human-Machine Perception Laboratory, Department of Computer Science and Engineering, University of Nevada, Reno, Nevada, United States.
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14
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Chesnut RM, Aguilera S, Buki A, Bulger EM, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin RG, Ghajar J, Harris O, Hawryluk GWJ, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo DO, Patel MB, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein DM, Stocchetti N, Taccone FS, Timmons SD, Tsai EC, Ullman JS, Videtta W, Wright DW, Zammit C. Perceived Utility of Intracranial Pressure Monitoring in Traumatic Brain Injury: A Seattle International Brain Injury Consensus Conference Consensus-Based Analysis and Recommendations. Neurosurgery 2023; 93:399-408. [PMID: 37171175 PMCID: PMC10319366 DOI: 10.1227/neu.0000000000002516] [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: 10/15/2022] [Accepted: 01/02/2023] [Indexed: 05/13/2023] Open
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is widely practiced, but the indications are incompletely developed, and guidelines are poorly followed. OBJECTIVE To study the monitoring practices of an established expert panel (the clinical working group from the Seattle International Brain Injury Consensus Conference effort) to examine the match between monitoring guidelines and their clinical decision-making and offer guidance for clinicians considering monitor insertion. METHODS We polled the 42 Seattle International Brain Injury Consensus Conference panel members' ICP monitoring decisions for virtual patients, using matrices of presenting signs (Glasgow Coma Scale [GCS] total or GCS motor, pupillary examination, and computed tomography diagnosis). Monitor insertion decisions were yes, no, or unsure (traffic light approach). We analyzed their responses for weighting of the presenting signs in decision-making using univariate regression. RESULTS Heatmaps constructed from the choices of 41 panel members revealed wider ICP monitor use than predicted by guidelines. Clinical examination (GCS) was by far the most important characteristic and differed from guidelines in being nonlinear. The modified Marshall computed tomography classification was second and pupils third. We constructed a heatmap and listed the main clinical determinants representing 80% ICP monitor insertion consensus for our recommendations. CONCLUSION Candidacy for ICP monitoring exceeds published indicators for monitor insertion, suggesting the clinical perception that the value of ICP data is greater than simply detecting and monitoring severe intracranial hypertension. Monitor insertion heatmaps are offered as potential guidance for ICP monitor insertion and to stimulate research into what actually drives monitor insertion in unconstrained, real-world conditions.
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Affiliation(s)
- Randall M. Chesnut
- Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
- Department of Orthopaedic Surgery, University of Washington, Seattle, Washington, USA
- School of Global Health, University of Washington, Seattle, Washington, USA
- Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Sergio Aguilera
- Almirante Nef Naval Hospital, Valparaiso University, Viña Del Mar, Chile
- Valparaiso University, Valparaiso, Chile
| | - Andras Buki
- Department of Neurosurgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Eileen M. Bulger
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, Washington, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- Neuroscience Department, NeuroIntensive Care Unit, Fondazione IRCCS San Gerardo dei Tintori, Monza, Monza, Italy
| | - D. Jamie Cooper
- Intensive Care Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Ramon Diaz Arrastia
- Department of Neurology, Penn Presbyterian Medical Center, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael Diringer
- Department of Neurology, Washington University School of Medicine, St Louis, USA
- Department of Neurology, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, Groote Schuur Hospital, University of Cape Town, Observatory 7925, South Africa
| | - Guoyi Gao
- Department of Neurosurgery, Renji Hospital, Shanghai Institute of Head Trauma, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Romergryko G. Geocadin
- Departments of Neurology, Neurological Surgery, Anesthesiology-Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jamshid Ghajar
- Department of Neurosurgery, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | - Odette Harris
- Department of Neurosurgery, Stanford University School of Medicine, Center for Academic Medicine, Stanford, California, USA
| | - Gregory W. J. Hawryluk
- Cleveland Clinic Akron General Neurosciences Center, Fairlawn, Ohio, USA
- Uniformed Services University, Bethesda, Maryland, USA
- Brain Trauma Foundation, New York City, New York, USA
| | - Alan Hoffer
- UH Cleveland Medical Center, Cleveland, Ohio, USA
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge and Cambridge Biomedical Campus, Cambridge, UK
| | - Mathew Joseph
- Department of Neurological Sciences, Christian Medical College, Vellore, Tamil Nadu, India
| | - Ryan Kitagawa
- Vivian L Smith Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas, USA
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California, USA
- Department of Neurosurgery, Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Stephan Mayer
- Westchester Health Network, New York Medical College, Valhalla, New York, USA
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge and Addenbrooke's Hospital, Cambridge, UK
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Daniel B. Michael
- Department of Neurosurgery, Beaumont Health, Michigan Head and Spine Institute, Oakland University William Beaumont School of Medicine, Southfield, Michigan, USA
| | - Mauro Oddo
- CHUV Medical Directorate and Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center Presbyterian, Pittsburgh, Pennsylvania, USA
| | - Mayur B. Patel
- Department of Surgery, Division of Acute Care Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - Jeffrey V. Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia
- Department of Surgery, Monash University, Melbourne, Australia
| | - Andres M. Rubiano
- INUB/MEDITECH Research Group, Neurosciences Institute, El Bosque University, Bogotá, Colombia
- MEDITECH Foundation, Clinical Research, Cali, Colombia
| | - Juain Sahuquillo
- Department of Neurosurgery, Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona: Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron Institut de Recerca (VHIR), Barcelona, Spain
| | - Franco Servadei
- Department of Biomedical Sciences, Humanitas University and IRCCS Humanitas Research Hospital, Milano, Italy
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Deborah M. Stein
- University of Maryland School of Medicine, Adult Critical Care Services, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Shelly D. Timmons
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Eve C. Tsai
- Suruchi Bhargava Chair in Spinal Cord and Brain Regeneration Research, The Ottawa Hospital, Department of Surgery, Division of Neurosurgery, University of Ottawa, Civic Campus, Ottawa, Ontario, Canada
| | - Jamie S. Ullman
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York, USA
| | - Walter Videtta
- Intensive Care, Posadas Hospital, Buenos Aires, Argentina
| | - David W. Wright
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Christopher Zammit
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
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15
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Kashkoush AI, Potter T, Petitt JC, Hu S, Hunter K, Kelly ML. Novel application of the Rotterdam CT score in the prediction of intracranial hypertension following severe traumatic brain injury. J Neurosurg 2023; 138:1050-1057. [PMID: 35962965 DOI: 10.3171/2022.6.jns212921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 06/17/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Severe traumatic brain injury (TBI) is associated with intracranial hypertension (ICHTN). The Rotterdam CT score (RS) can predict clinical outcomes following TBI, but the relationship between the RS and ICHTN is unknown. The purpose of this study was to investigate clinical and radiological factors that predict ICHTN in patients with severe TBI. METHODS The authors performed a single-center retrospective review of patients who, between 2018 and 2021, had an intracranial pressure (ICP) monitor placed following TBI. Radiological and clinical characteristics related to the TBI and ICP monitoring were collected. The main outcome of interest was ICHTN, which was a dichotomous outcome (yes or no) defined on a per-patient basis as an ICP > 22 mm Hg that persisted for at least 5 minutes and required an escalation of treatment. ICHTN included both elevated opening pressure on initial monitor placement and ICP elevations later during hospitalization. Multivariate logistic regression was performed to determine variables associated with ICHTN. Diagnostic accuracy was evaluated using the area under the receiver operating characteristic curve (AUROC). RESULTS Seventy patients with severe TBI and an ICP monitor were included in this study. There was a predominance of male patients (94.0%), and the mean patient age was 40 years old. Most patients (67%) had an intraparenchymal catheter placed, whereas 33% of patients had a ventriculostomy catheter placed. In the multivariate logistic regression analysis, the RS was an independent predictor of ICHTN (OR 2.0, 95% CI 1.2-3.5, p = 0.014). No instances of ICHTN were observed in patients with an RS of 2 or less and no sulcal effacement. The AUROC of the RS and sulcal effacement was higher than the AUROC of the RS alone for predicting ICHTN (0.76 vs 0.71, p = 0.003, z-test). CONCLUSIONS The RS was predictive of ICHTN in patients with severe TBI, and the diagnostic accuracy of the model was improved with the inclusion of sulcal effacement at the vertex on CT of the head. Patients with a low RS and no sulcal effacement are likely at low risk for the development of ICHTN.
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Affiliation(s)
| | - Tamia Potter
- 2Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland; and
| | - Jordan C Petitt
- 2Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland; and
| | - Song Hu
- 3Department of Radiology, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Kyle Hunter
- 3Department of Radiology, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, Ohio
| | - Michael L Kelly
- 2Department of Neurological Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland; and
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16
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Ahluwalia M, Mcmichael H, Kumar M, Espinosa MP, Bosomtwi A, Lu Y, Khodadadi H, Jarrahi A, Khan MB, Hess DC, Rahimi SY, Vender JR, Vale FL, Braun M, Baban B, Dhandapani KM, Vaibhav K. Altered endocannabinoid metabolism compromises the brain-CSF barrier and exacerbates chronic deficits after traumatic brain injury in mice. Exp Neurol 2023; 361:114320. [PMID: 36627040 PMCID: PMC9904276 DOI: 10.1016/j.expneurol.2023.114320] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 12/07/2022] [Accepted: 01/06/2023] [Indexed: 01/09/2023]
Abstract
Endocannabinoids [2-arachidonoylglycerol (2-AG) and N-arachidonoylethanolamine (AEA)], endogenously produced arachidonate-based lipids, are anti-inflammatory physiological ligands for two known cannabinoid receptors, CB1 and CB2, yet the molecular and cellular mechanisms underlying their effects after brain injury are poorly defined. In the present study, we hypothesize that traumatic brain injury (TBI)-induced loss of endocannabinoids exaggerates neurovascular injury, compromises brain-cerebrospinal fluid (CSF) barriers (BCB) and causes behavioral dysfunction. Preliminary analysis in human CSF and plasma indicates changes in endocannabinoid levels. This encouraged us to investigate the levels of endocannabinoid-metabolizing enzymes in a mouse model of controlled cortical impact (CCI). Reductions in endocannabinoid (2-AG and AEA) levels in plasma were supported by higher expression of their respective metabolizing enzymes, monoacylglycerol lipase (MAGL), fatty acid amide hydrolase (FAAH), and cyclooxygenase 2 (Cox-2) in the post-TBI mouse brain. Following increased metabolism of endocannabinoids post-TBI, we observed increased expression of CB2, non-cannabinoid receptor Transient receptor potential vanilloid-1 (TRPV1), aquaporin 4 (AQP4), ionized calcium binding adaptor molecule 1 (IBA1), glial fibrillary acidic protein (GFAP), and acute reduction in cerebral blood flow (CBF). The BCB and pericontusional cortex showed altered endocannabinoid expressions and reduction in ventricular volume. Finally, loss of motor functions and induced anxiety behaviors were observed in these TBI mice. Taken together, our findings suggest endocannabinoids and their metabolizing enzymes play an important role in the brain and BCB integrity and highlight the need for more extensive studies on these mechanisms.
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Affiliation(s)
- Meenakshi Ahluwalia
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Hannah Mcmichael
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Manish Kumar
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Mario P Espinosa
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Asamoah Bosomtwi
- Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Yujiao Lu
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Hesam Khodadadi
- Department of Oral Biology and Diagnostic Sciences, Center for Excellence in Research, Scholarship and Innovation, Dental College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Abbas Jarrahi
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Mohammad Badruzzaman Khan
- Department of Neurology, Neuroscience Center of Excellence, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - David C Hess
- Department of Neurology, Neuroscience Center of Excellence, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Scott Y Rahimi
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - John R Vender
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Fernando L Vale
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Molly Braun
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America; Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, United States of America; VISN 20 Mental Illness Research, Education and Clinical Center (MIRECC), VA Puget Sound Health Care System, Seattle, WA, United States of America
| | - Babak Baban
- Department of Oral Biology and Diagnostic Sciences, Center for Excellence in Research, Scholarship and Innovation, Dental College of Georgia, Augusta University, Augusta, GA, United States of America; Department of Neurology, Neuroscience Center of Excellence, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Krishnan M Dhandapani
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America
| | - Kumar Vaibhav
- Department of Neurosurgery, Medical College of Georgia, Augusta University, Augusta, GA, United States of America; Department of Oral Biology and Diagnostic Sciences, Center for Excellence in Research, Scholarship and Innovation, Dental College of Georgia, Augusta University, Augusta, GA, United States of America.
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17
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Maye H, Waqar M, Colombo F, Lekka E. External validation of the GCS-Pupils Score as an outcome predictor after traumatic brain injury in adults: a single-center experience. Acta Neurochir (Wien) 2023; 165:289-297. [PMID: 36484865 DOI: 10.1007/s00701-022-05431-3] [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: 07/14/2022] [Accepted: 11/18/2022] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The GCS-Pupils (GCS-P) score is a recently described scoring system to aid outcome prediction in patients with traumatic brain injury (TBI). The aim of this study was to provide the first external validation of the GCS-P score by identifying independent predictors of outcome in TBI patients. METHODS Review of prospective adult (≥ 16 years) TBI database at a tertiary neurosurgical center with a catchment population of 1.5 million over a 12-month period commencing October 2016. Multivariate logistic regression was used to identify predictors of discharge destination and 30-day mortality. RESULTS Three hundred and fifty-eight patients were included. The median age was 60 years with a male predominance of 64%. The median GCS-P was 14 (interquartile range 12-15) and the commonest GCS-P category was mild (13-15; 238/358, 66%). Discharge destination was home in 69% of patients and rehab services or equivalent in 31%. Multivariate analysis identified age (p = 0.01), CT findings of an acute subdural hematoma (p = 0.01) or diffuse axonal injury (p = 0.02), and a neurosurgical operation (p = 0.02) as independent predictors of discharge destination. The 30-day mortality rate was 11%. Within the category of severe TBI (GCS-P ≤ 8), GCS-P was able to identify patients with a very high likelihood of 30-day mortality (GCS-P ≤ 4; 16/31, 52%). Multivariate analysis revealed the Charlson comorbidity score (p = 0.01), GCS-P (p = 0.02), and traumatic subarachnoid hemorrhage (p = 0.05) as independent predictors of mortality. CONCLUSION The GCS-P is a useful predictor of 30-day mortality, although its usefulness for other clinical outcomes remains to be proven.
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Affiliation(s)
- Helen Maye
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Stott Lane, Manchester, M6 8HD, UK.
| | - Mueez Waqar
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Stott Lane, Manchester, M6 8HD, UK
| | - Francesca Colombo
- Department of Neurosurgery, Manchester Center for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Stott Lane, Manchester, M6 8HD, UK
| | - Elvira Lekka
- Department of Neurosurgery, Royal Preston Hospital, Preston, UK
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18
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Dong JF, Zhang F, Zhang J. Detecting traumatic brain injury-induced coagulopathy: What we are testing and what we are not. J Trauma Acute Care Surg 2023; 94:S50-S55. [PMID: 35838367 PMCID: PMC9805481 DOI: 10.1097/ta.0000000000003748] [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] [Indexed: 02/07/2023]
Abstract
ABSTRACT Coagulopathy after traumatic brain injury (TBI) is common and has been closely associated with poor clinical outcomes for the affected patients. Traumatic brain injury-induced coagulopathy (TBI-IC) is consumptive in nature and evolves rapidly from an injury-induced hypercoagulable state. Traumatic brain injury-induced coagulopathy defined by laboratory tests is significantly more frequent than clinical coagulopathy, which often manifests as secondary, recurrent, or delayed intracranial or intracerebral hemorrhage. This disparity between laboratory and clinical coagulopathies has hindered progress in understanding the pathogenesis of TBI-IC and developing more accurate and predictive tests for this severe TBI complication. In this review, we discuss laboratory tests used in clinical and research studies to define TBI-IC, with specific emphasis on what the tests detect and what they do not. We also offer perspective on developing more accurate and predictive tests for this severe TBI complication.
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Affiliation(s)
- Jing-fei Dong
- Bloodworks Research Institute, Seattle, WA, USA
- Division of Hematology, Department of Medicine, University of Washington, School of Medicine, Seattle, WA, USA
| | - Fangyi Zhang
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Jianning Zhang
- Tianjin Institute of Neurology, Tianjin, China
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
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19
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Tripathi R, Gupta R, Sahu M, Srivastava D, Das A, Ambasta RK, Kumar P. Free radical biology in neurological manifestations: mechanisms to therapeutics interventions. ENVIRONMENTAL SCIENCE AND POLLUTION RESEARCH INTERNATIONAL 2022; 29:62160-62207. [PMID: 34617231 DOI: 10.1007/s11356-021-16693-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 09/20/2021] [Indexed: 06/13/2023]
Abstract
Recent advancements and growing attention about free radicals (ROS) and redox signaling enable the scientific fraternity to consider their involvement in the pathophysiology of inflammatory diseases, metabolic disorders, and neurological defects. Free radicals increase the concentration of reactive oxygen and nitrogen species in the biological system through different endogenous sources and thus increased the overall oxidative stress. An increase in oxidative stress causes cell death through different signaling mechanisms such as mitochondrial impairment, cell-cycle arrest, DNA damage response, inflammation, negative regulation of protein, and lipid peroxidation. Thus, an appropriate balance between free radicals and antioxidants becomes crucial to maintain physiological function. Since the 1brain requires high oxygen for its functioning, it is highly vulnerable to free radical generation and enhanced ROS in the brain adversely affects axonal regeneration and synaptic plasticity, which results in neuronal cell death. In addition, increased ROS in the brain alters various signaling pathways such as apoptosis, autophagy, inflammation and microglial activation, DNA damage response, and cell-cycle arrest, leading to memory and learning defects. Mounting evidence suggests the potential involvement of micro-RNAs, circular-RNAs, natural and dietary compounds, synthetic inhibitors, and heat-shock proteins as therapeutic agents to combat neurological diseases. Herein, we explain the mechanism of free radical generation and its role in mitochondrial, protein, and lipid peroxidation biology. Further, we discuss the negative role of free radicals in synaptic plasticity and axonal regeneration through the modulation of various signaling molecules and also in the involvement of free radicals in various neurological diseases and their potential therapeutic approaches. The primary cause of free radical generation is drug overdosing, industrial air pollution, toxic heavy metals, ionizing radiation, smoking, alcohol, pesticides, and ultraviolet radiation. Excessive generation of free radicals inside the cell R1Q1 increases reactive oxygen and nitrogen species, which causes oxidative damage. An increase in oxidative damage alters different cellular pathways and processes such as mitochondrial impairment, DNA damage response, cell cycle arrest, and inflammatory response, leading to pathogenesis and progression of neurodegenerative disease other neurological defects.
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Affiliation(s)
- Rahul Tripathi
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Delhi, India
| | - Rohan Gupta
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Delhi, India
| | - Mehar Sahu
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Delhi, India
| | - Devesh Srivastava
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Delhi, India
| | - Ankita Das
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Delhi, India
| | - Rashmi K Ambasta
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Delhi, India
| | - Pravir Kumar
- Molecular Neuroscience and Functional Genomics Laboratory, Delhi Technological University (Formerly Delhi College of Engineering), Delhi, India.
- , Delhi, India.
- Molecular Neuroscience and Functional Genomics Laboratory, Shahbad Daulatpur, Bawana Road, Delhi, 110042, India.
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20
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Tu KC, Eric Nyam TT, Wang CC, Chen NC, Chen KT, Chen CJ, Liu CF, Kuo JR. A Computer-Assisted System for Early Mortality Risk Prediction in Patients with Traumatic Brain Injury Using Artificial Intelligence Algorithms in Emergency Room Triage. Brain Sci 2022; 12:brainsci12050612. [PMID: 35624999 PMCID: PMC9138998 DOI: 10.3390/brainsci12050612] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 05/05/2022] [Indexed: 01/27/2023] Open
Abstract
Traumatic brain injury (TBI) remains a critical public health challenge. Although studies have found several prognostic factors for TBI, a useful early predictive tool for mortality has yet to be developed in the triage of the emergency room. This study aimed to use machine learning algorithms of artificial intelligence (AI) to develop predictive models for TBI patients in the emergency room triage. We retrospectively enrolled 18,249 adult TBI patients in the electronic medical records of three hospitals of Chi Mei Medical Group from January 2010 to December 2019, and undertook the 12 potentially predictive feature variables for predicting mortality during hospitalization. Six machine learning algorithms including logistical regression (LR) random forest (RF), support vector machines (SVM), LightGBM, XGBoost, and multilayer perceptron (MLP) were used to build the predictive model. The results showed that all six predictive models had high AUC from 0.851 to 0.925. Among these models, the LR-based model was the best model for mortality risk prediction with the highest AUC of 0.925; thus, we integrated the best model into the existed hospital information system for assisting clinical decision-making. These results revealed that the LR-based model was the best model to predict the mortality risk in patients with TBI in the emergency room. Since the developed prediction system can easily obtain the 12 feature variables during the initial triage, it can provide quick and early mortality prediction to clinicians for guiding deciding further treatment as well as helping explain the patient’s condition to family members.
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Affiliation(s)
- Kuan-Chi Tu
- Department of Neurosurgery, Chi Mei Medical Center, Tainan 710402, Taiwan; (K.-C.T.); (T.-T.E.N.); (C.-C.W.)
| | - Tee-Tau Eric Nyam
- Department of Neurosurgery, Chi Mei Medical Center, Tainan 710402, Taiwan; (K.-C.T.); (T.-T.E.N.); (C.-C.W.)
| | - Che-Chuan Wang
- Department of Neurosurgery, Chi Mei Medical Center, Tainan 710402, Taiwan; (K.-C.T.); (T.-T.E.N.); (C.-C.W.)
- Center for General Education, Southern Taiwan University of Science and Technology, Tainan 710402, Taiwan
| | - Nai-Ching Chen
- Department of Nursing, Chi Mei Medical Center, Tainan 710402, Taiwan;
| | - Kuo-Tai Chen
- Department of Emergency, Chi Mei Medical Center, Tainan 710402, Taiwan;
| | - Chia-Jung Chen
- Department of Information Systems, Chi Mei Medical Center, Tainan 710402, Taiwan;
| | - Chung-Feng Liu
- Department of Medical Research, Chi Mei Medical Center, Tainan 710402, Taiwan;
| | - Jinn-Rung Kuo
- Department of Neurosurgery, Chi Mei Medical Center, Tainan 710402, Taiwan; (K.-C.T.); (T.-T.E.N.); (C.-C.W.)
- Center for General Education, Southern Taiwan University of Science and Technology, Tainan 710402, Taiwan
- Correspondence: ; Tel.: +886-6-281-2811-57423
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21
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Wang J, Xie X, Wu Y, Zhou Y, Li Q, Li Y, Xu X, Wang M, Murdiyarso L, Houck K, Hilton T, Chung D, Li M, Zhang JN, Dong J. Brain-Derived Extracellular Vesicles Induce Vasoconstriction and Reduce Cerebral Blood Flow in Mice. J Neurotrauma 2022; 39:879-890. [PMID: 35316073 DOI: 10.1089/neu.2021.0274] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) impairs cerebrovascular autoregulation and reduces cerebral blood flow (CBF), leading to ischemic secondary injuries. We have shown that injured brains release brain-derived extracellular vesicles (BDEVs) into circulation, where they cause a systemic hypercoagulable state that rapidly turns into consumptive coagulopathy. BDEVs induce endothelial injury and permeability, leading to the hypothesis that they contribute to TBI-induced cerebrovascular dysregulation. In a study designed to test this hypothesis, we detected circulating BDEVs in C57BL/6J mice subjected to severe TBI, reaching peak levels of 3x104/µl at 3 hours post injury (71.2±21.5% of total annexin V-binding EVs). We further showed in an adaptive transfer model that 41.7±5.8% of non-injured mice died within 6 hours after being infused with 3x104/µl of BDEVs. BDEVs transmigrated through the vessel walls, induced rapid vasoconstriction by inducing calcium influx in vascular smooth muscle cells, and reduced CBF by 93.8±5.6% within 30 minutes after infusion. The CBF suppression was persistent in mice that eventually died but it recovered quickly in surviving mice. It was prevented by the calcium channel blocker nimodipine. When being separated, neither protein nor phospholipid components from the lethal number of BDEVs induced vasoconstriction, reduced CBF, and caused death. These results demonstrate a novel vasoconstrictive activity of BDEVs that depends on the structure of BDEVs and contributes to TBI-induced disseminated cerebral ischemia and sudden death.
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Affiliation(s)
- Jiwei Wang
- Tianjin Neurological Institute, 230967, Anshan road No.154, Tianjin, China, 300052;
| | - Xiaofeng Xie
- Lanzhou University, 12426, Lanzhou, Gansu, China;
| | - Yingang Wu
- University of Science and Technology of China, 12652, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine., Hefei, Anhui, China;
| | - Yuan Zhou
- Tianjin Neurological Institute, 230967, Tianjin Medical University General Hospital, Tianjin, Tianjin, China;
| | - Qifeng Li
- Tianjin Neurological Institute, 230967, Tianjin Medical University General Hospital, Tianjin, Tianjin, China;
| | - Ying Li
- Tianjin Neurological Institute, 230967, Tianjin, Tianjin, China;
| | - Xin Xu
- Tianjin Neurological Institute, 230967, Tianjin Medical University General Hospital, Tianjin, Tianjin, China;
| | - Min Wang
- Lanzhou University, 12426, Lanzhou, Gansu, China;
| | | | - Katie Houck
- Bloodworks Research institute, Seattle, United States;
| | | | - Dominic Chung
- Bloodworks Research institute, Seattle, United States;
| | - Min Li
- Lanzhou University, 12426, Lanzhou, Gansu, China;
| | - Jian-Ning Zhang
- Tianjin Neurological Institute, 230967, Tianjin Medical University General Hospital, Tianjin, Tianjin, China;
| | - Jingfei Dong
- Bloodworks Research Institute, Bloodworks Northwest, Seattle, Seattle, Washington, United States.,Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington, United States;
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22
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Sheth KN, Yuen MM, Mazurek MH, Cahn BA, Prabhat AM, Salehi S, Shah JT, By S, Welch EB, Sofka M, Sacolick LI, Kim JA, Payabvash S, Falcone GJ, Gilmore EJ, Hwang DY, Matouk C, Gordon-Kundu B, Rn AW, Petersen N, Schindler J, Gobeske KT, Sansing LH, Sze G, Rosen MS, Kimberly WT, Kundu P. Bedside detection of intracranial midline shift using portable magnetic resonance imaging. Sci Rep 2022; 12:67. [PMID: 34996970 PMCID: PMC8742125 DOI: 10.1038/s41598-021-03892-7] [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: 03/29/2021] [Accepted: 12/02/2021] [Indexed: 12/17/2022] Open
Abstract
Neuroimaging is crucial for assessing mass effect in brain-injured patients. Transport to an imaging suite, however, is challenging for critically ill patients. We evaluated the use of a low magnetic field, portable MRI (pMRI) for assessing midline shift (MLS). In this observational study, 0.064 T pMRI exams were performed on stroke patients admitted to the neuroscience intensive care unit at Yale New Haven Hospital. Dichotomous (present or absent) and continuous MLS measurements were obtained on pMRI exams and locally available and accessible standard-of-care imaging exams (CT or MRI). We evaluated the agreement between pMRI and standard-of-care measurements. Additionally, we assessed the relationship between pMRI-based MLS and functional outcome (modified Rankin Scale). A total of 102 patients were included in the final study (48 ischemic stroke; 54 intracranial hemorrhage). There was significant concordance between pMRI and standard-of-care measurements (dichotomous, κ = 0.87; continuous, ICC = 0.94). Low-field pMRI identified MLS with a sensitivity of 0.93 and specificity of 0.96. Moreover, pMRI MLS assessments predicted poor clinical outcome at discharge (dichotomous: adjusted OR 7.98, 95% CI 2.07–40.04, p = 0.005; continuous: adjusted OR 1.59, 95% CI 1.11–2.49, p = 0.021). Low-field pMRI may serve as a valuable bedside tool for detecting mass effect.
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Affiliation(s)
- Kevin N Sheth
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA.
| | - Matthew M Yuen
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Mercy H Mazurek
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Bradley A Cahn
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Anjali M Prabhat
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | - Jill T Shah
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | | | | | | | - Jennifer A Kim
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | | | - Guido J Falcone
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Emily J Gilmore
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Barbara Gordon-Kundu
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Adrienne Ward Rn
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, CT, USA
| | - Nils Petersen
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Joseph Schindler
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Kevin T Gobeske
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Lauren H Sansing
- Department of Neurology, Yale School of Medicine, 15 York Street, LLCI Room 1003C, P.O. Box 208018, New Haven, CT, 06520, USA
| | - Gordon Sze
- Department of Neuroradiology, Yale School of Medicine, New Haven, CT, USA
| | - Matthew S Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown, MA, USA
| | - W Taylor Kimberly
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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23
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Early death prediction in children with traumatic brain injury using computed tomography scoring systems. J Clin Neurosci 2021; 95:164-171. [PMID: 34929641 DOI: 10.1016/j.jocn.2021.12.007] [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: 09/10/2021] [Revised: 11/05/2021] [Accepted: 12/05/2021] [Indexed: 11/21/2022]
Abstract
PURPOSE Marshall and Rotterdam are the most commonly used CT scoring systems to predict the outcome following traumatic brain injury (TBI). Although several studies have compared the performance of the two scoring systems in adult patients, none of these studies has evaluated the performance of the two scoring systems in pediatric patients. This study aimed to determine the predictive value of the Marshall and Rotterdam scoring systems in pediatric patients with TBI. METHODS This retrospective study included 105 children with admission GCS < 12, with a mean age of 6.2 (±3.5) years. Their initial CT and status at hospital discharge (dead or alive) were reviewed, and both the Marshall and Rotterdam scores were calculated. We examined whether each score was related to the early death of pediatric patients. RESULTS The pediatric patients with higher Marshall and Rotterdam scores had a higher mortality rate. There was a good correlation between the Marshall and Rotterdam scoring systems (Spearman's rho = 0.618, significant at the 0.05 level). Both systems demonstrated a high degree of discrimination when predicting early mortality. The Marshall scoring system had reasonable discrimination (AUC 0.782), and the Rotterdam scoring system had good discrimination (AUC 0.729). Comparing the two CT scoring systems, the Marshall scoring system provided a better positive predictive value (90%) for early mortality than the Rotterdam scoring system (78%). CONCLUSIONS Both the Marshall and Rotterdam scoring systems have good predictability for assessing mortality in pediatric patients with TBI. The performance of the Marshall scoring system was equal to or slightly better than that of the Rotterdam scoring system.
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24
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Palekar SG, Jaiswal M, Patil M, Malpathak V. Outcome Prediction in Patients of Traumatic Brain Injury Based on Midline Shift on CT Scan of Brain. INDIAN JOURNAL OF NEUROSURGERY 2021. [DOI: 10.1055/s-0040-1716990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Background Clinicians treating patients with head injury often take decisions based on their assessment of prognosis. Assessment of prognosis could help communication with a patient and the family. One of the most widely used clinical tools for such prediction is the Glasgow coma scale (GCS); however, the tool has a limitation with regard to its use in patients who are under sedation, are intubated, or under the influence of alcohol or psychoactive drugs. CT scan findings such as status of basal cistern, midline shift, associated traumatic subarachnoid hemorrhage (SAH), and intraventricular hemorrhage are useful indicators in predicting outcome and also considered as valid options for prognostication of the patients with traumatic brain injury (TBI), especially in emergency setting.
Materials and Methods 108 patients of head injury were assessed at admission with clinical examination, history, and CT scan of brain. CT findings were classified according to type of lesion and midline shift correlated to GCS score at admission. All the subjects in this study were managed with an identical treatment protocol. Outcome of these patients were assessed on GCS score at discharge.
Results Among patients with severe GCS, 51% had midline shift. The degree of midline shift in CT head was a statistically significant determinant of outcome (p = 0.023). Seventeen out of 48 patients (35.4%) with midline shift had poor outcome as compared with 8 out of 60 patients (13.3%) with no midline shift.
Conclusion In patients with TBI, the degree of midline shift on CT scan was significantly related to the severity of head injury and resulted in poor clinical outcome.
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Affiliation(s)
- Shrikant Govindrao Palekar
- Department of General Surgery, Dr. Vasantrao Pawar Medical College, Hospital & research center, Adgaon, Nasik, India
| | - Manish Jaiswal
- Department of Neurosurgery, King George’s Medical University, Lucknow, Uttar Pradesh, India
| | - Mandar Patil
- Department of Neurosurgery, Tirunelveli Government Medical College, Tamil Nadu, India
| | - Vijay Malpathak
- Department of General Surgery, Dr. Vasantrao Pawar Medical College, Hospital & research center, Adgaon, Nasik, India
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25
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Kim MS, Cho MJ, Kim JW, Jang SH. White Matter Abnormalities in Traumatic Subarachnoid Hemorrhage: A Tract-Based Spatial Statistics Study. Med Sci Monit 2021; 27:e933959. [PMID: 34657118 PMCID: PMC8529937 DOI: 10.12659/msm.933959] [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] [Indexed: 12/02/2022] Open
Abstract
Background The pathophysiology of traumatic subarachnoid hemorrhage and brain injury has not been fully elucidated. In this study, we examined abnormalities of white matter in isolated traumatic subarachnoid hemorrhage patients by applying tract-based spatial statistics. Material/Methods For this study, 10 isolated traumatic subarachnoid hemorrhage patients and 10 age- and sex-matched healthy control subjects were recruited. Fractional anisotropy data voxel-wise statistical analyses were conducted through the tract-based spatial statistics as implemented in the FMRIB Software Library. Depending on the intersection between the fractional anisotropy skeleton and the probabilistic white matter atlases of Johns Hopkins University, we calculated mean fractional anisotropy values within the entire tract skeleton and 48 regions of interest. Results The fractional anisotropy values for 19 of 48 regions of interest showed significant divergences (P<0.05) between the patient group and control group. The regions showing significant differences included the corpus callosum and its adjacent neural structures, the brainstem and its adjacent neural structures, and the subcortical white matter that passes the long neural tract. Conclusions The results demonstrated abnormalities of white matter in traumatic subarachnoid hemorrhage patients, and the abnormality locations are compatible with areas that are vulnerable to diffuse axonal injury. Based on these results, traumatic subarachnoid hemorrhage patients also exhibit diffuse axonal injuries; thus, traumatic subarachnoid hemorrhage could be an indicator of the presence of severe brain injuries associated with acute or excessive mechanical forces.
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Affiliation(s)
- Min Son Kim
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Namku, Taegu, South Korea
| | - Min Jye Cho
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Namku, Taegu, South Korea
| | - Jae Woon Kim
- Department of Radiology, College of Medicine, Yeungnam University, Namku, Taegu, South Korea
| | - Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, College of Medicine, Yeungnam University, Namku, Taegu, South Korea
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Zhang X, Wang D, Tian Y, Wei H, Liu X, Xiang T, Fan Y, Gao C, Huang J, Sha Z, Quan W, Zhang J, Jiang R. Risk Factors for Atorvastatin as a Monotherapy for Chronic Subdural Hematoma: A Retrospective Multifactor Analysis. Front Aging Neurosci 2021; 13:726592. [PMID: 34539386 PMCID: PMC8440973 DOI: 10.3389/fnagi.2021.726592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/09/2021] [Indexed: 11/23/2022] Open
Abstract
Chronic subdural hematoma (CSDH) is a common form of intracranial hemorrhage in the aging population. We aimed to investigate the predictive factors for atorvastatin efficacy as a monotherapy for moderate CSDH. We retrospectively reviewed the medical records of patients who were diagnosed with moderate CSDH and received atorvastatin monotherapy between February 5, 2014, and November 7, 2015, in multiple neurosurgical departments. Univariate, multivariate and receiver operating characteristic curve analyses were performed to identify the potential significant factors indicative of the good therapeutic efficacy or poor therapeutic efficacy of atorvastatin for mild CSDH, such as age, sex, history of injury, Markwalder grading scale-Glasgow Coma Scale (MGS-GCS), Activities of Daily Life-the Barthel Index scale (ADL-BI), American Society of Anesthesiologists Physical Status classification system (ASA-PS), blood cell counts, serum levels and computed tomography findings. A total of 89 patients (75 men and 14 women) aged 24-88 years (mean age 61.95 ± 15.30 years) were followed-up for 24 weeks. Computed tomography findings at admission showed mixed-density hematoma in 22 patients, isodense hematoma in 13 patients, high-density hematoma in 26 patients, and low-density hematoma in 28 patients. In total, 3, 80, and 6 patients had MGS-GCS grades of 0, 1, and 2, respectively. The efficacy rate at 6 months was 87.6% (78/89). Eleven patients were switched to surgery due to a worsened neurological condition, of whom 8, 1, 1, and 1 had high-density, low-density, isodense and mixed-density hematomas, respectively. These patients were switched to surgery over a range of 2-27 days, with a median interval of 12 days after the medication treatment. Univariate and multivariate analyses, confirmed by ROC curves, revealed that high-density hematoma, basal cistern compression, and hematoma volume to be independent risk factors for the efficacy of atorvastatin monotherapy in patients with moderate CSDH. Atorvastatin is an effective monotherapy for the treatment of mild CSDH. High-density hematoma, basal cistern compression, and hematoma volume are independent predictors of the efficacy of atorvastatin as a non-surgical treatment. The results suggested that ADL-BI was more sensitive than the MGS-GCS and ASA-PS for determining patient outcomes in our moderate CSDH cohort.
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Affiliation(s)
- Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Dong Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Ye Tian
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Huijie Wei
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Chuang Gao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jinhao Huang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Wei Quan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Medical University General Hospital, Ministry of Education, Tianjin, China
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Tomasi SO, Umana GE, Scalia G, Rubio-Rodriguez RL, Raudino G, Rechberger J, Geiger P, Chaurasia B, Yaǧmurlu K, Lawton MT, Winkler PA. Perforating Arteries of the Lemniscal Trigone: A Microsurgical Neuroanatomic Description. Front Neuroanat 2021; 15:675313. [PMID: 34512277 PMCID: PMC8427497 DOI: 10.3389/fnana.2021.675313] [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: 03/02/2021] [Accepted: 07/16/2021] [Indexed: 11/24/2022] Open
Abstract
Background: The perforating arteries in the dorsolateral zone of the midbrain play a crucial role in the functions of the brain stem. Their damage due to herniation, pathological lesions, or surgery, favored by the narrow tentorial incisura, can lead to hemorrhages or ischemia and subsequently to severe consequences for the patient. Objective: In literature, not much attention has been directed to the perforating arteries in the lemniscus; in fact, no reports on the perforators of this anatomical region are available. The present study aims to a detailed analysis of the microanatomy and the clinical implications of these perforators, in relation to the parent vessels. We focused on the small vessels that penetrate the midbrain's dorsolateral surface, known as lemniscal trigone, to understand better their microanatomy and their functional importance in the clinical practice during the microsurgical approach to this area. Methods: Eighty-seven alcohol-fixed cadaveric hemispheres (44 brains) without any pathological lesions provided the material for studying the perforating vessels and their origin around the dorsolateral midbrain using an operating microscope (OPMI 1 FC, Zeiss). Measurements of the perforators' distances, in relation to the parent vessels, were taken using a digital caliper. Results: An origin from the SCA could be found in 70.11% (61) and from the PCA in 27.58% (24) of the hemispheres. In one hemisphere, an origin from the posterior choroidal artery was found (4.54%). No perforating branches were discovered in 8.04% of specimens (7). Conclusion: The perforating arteries of the lemniscal trigone stem not only from the superior cerebellar artery (SCA), as described in the few studies available in literature, but also from the posterior cerebral artery (PCA). Therefore, special attention should be paid during surgery to spare those vessels and associated perforators. A comprehensive understanding of the lemniscal trigone's perforating arteries is vital to avoid infarction of the brainstem when treating midbrain tumors or vascular malformations.
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Affiliation(s)
- Santino Ottavio Tomasi
- Department of Neurological Surgery - Christian Doppler Klinik, Salzburg, Austria
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
- Laboratory for Microsurgical Neuroanatomy - Christian Doppler Klinik, Salzburg, Austria
| | - Giuseppe Emmanuele Umana
- Department of Neurosurgery, Cannizzaro Hospital, Trauma Center, Gamma Knife Center, Catania, Italy
| | - Gianluca Scalia
- Neurosurgery Unit, Highly Specialized Hospital and of National Importance “Garibaldi”, Catania, Italy
| | - Roberto Luis Rubio-Rodriguez
- Skull Base and Cerebrovascular Laboratory, University of California, San Francisco, San Francisco, CA, United States
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA, United States
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, United States
| | - Giuseppe Raudino
- Department of Neurosurgery - Humanitas, Istituto Clinico Catanese, Catania, Italy
| | - Julian Rechberger
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Philipp Geiger
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Bipin Chaurasia
- Department of Neurosurgery, Neurosurgery Clinic, Birgunj, Nepal
| | - Kaan Yaǧmurlu
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, United States
| | - Michael T. Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States
| | - Peter A. Winkler
- Department of Neurological Surgery - Christian Doppler Klinik, Salzburg, Austria
- Department of Neurosurgery, Paracelsus Medical University Salzburg, Salzburg, Austria
- Laboratory for Microsurgical Neuroanatomy - Christian Doppler Klinik, Salzburg, Austria
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Zhao L, Zhao SQ, Tang XP. Ruptured intracranial aneurysm presenting as cerebral circulation insufficiency: A case report. World J Clin Cases 2021; 9:6380-6387. [PMID: 34435002 PMCID: PMC8362555 DOI: 10.12998/wjcc.v9.i22.6380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/05/2021] [Accepted: 05/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Rupture of an intracranial aneurysm is a type of acute stroke that is a serious threat to human health. Misdiagnosis of ruptured intracranial aneurysms is a serious clinical event that may have disastrous consequences in some patients. To date, ruptured intracranial aneurysms have been misdiagnosed as meningitis, tumors, stroke, or trauma, among other conditions. Here, we report what appears to be the first case of a ruptured intracranial aneurysm that presented as cerebral circulation insufficiency.
CASE SUMMARY A middle-aged man was admitted to our hospital because of a parasellar lesion identified on a noncontrast computed tomography (CT) image after a mild traffic accident that was caused by a brief loss of consciousness. Notably, he was diagnosed with cerebral circulation insufficiency after two unexplained episodes of a transient loss of consciousness within the past 8 mo. The patient was diagnosed with right internal carotid artery aneurysm based on CT angiography and completely recovered after a craniotomy at our hospital. A few clots and severe adhesions around the aneurysm were observed in the subarachnoid space during the operation, suggesting that the aneurysm had ruptured and may had been misdiagnosed as cerebral circulation insufficiency.
CONCLUSION Ruptured intracranial aneurysms may show negative imaging results and present as cerebral circulation insufficiency, which should be recognized as soon as possible to ensure timely management.
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Affiliation(s)
- Long Zhao
- Department of Neurosurgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Shuang-Quan Zhao
- Department of Emergency Medicine, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
| | - Xiao-Ping Tang
- Department of Neurosurgery, The Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, Sichuan Province, China
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García-Pérez D, Panero-Pérez I, Eiriz Fernández C, Moreno-Gomez LM, Esteban-Sinovas O, Navarro-Main B, Gómez López PA, Castaño-León AM, Lagares A. Densitometric analysis of brain computed tomography as a new prognostic factor in patients with acute subdural hematoma. J Neurosurg 2021; 134:1940-1950. [PMID: 32736362 DOI: 10.3171/2020.4.jns193445] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 04/22/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Acute subdural hematoma (ASDH) is a major cause of mortality and morbidity after traumatic brain injury (TBI). Surgical evacuation is the mainstay of treatment in patients with altered neurological status or significant mass effect. Nevertheless, concerns regarding surgical indication still persist. Given that clinicians often make therapeutic decisions on the basis of their prognosis assessment, to accurately evaluate the prognosis is of great significance. Unfortunately, there is a lack of specific and reliable prognostic models. In addition, the interdependence of certain well-known predictive variables usually employed to guide surgical decision-making in ASDH has been proven. Because gray matter and white matter are highly susceptible to secondary insults during the early phase after TBI, the authors aimed to assess the extent of these secondary insults with a brain parenchyma densitometric quantitative CT analysis and to evaluate its prognostic capacity. METHODS The authors performed a retrospective analysis among their prospectively collected cohort of patients with moderate to severe TBI. Patients with surgically evacuated, isolated, unilateral ASDH admitted between 2010 and 2017 were selected. Thirty-nine patients were included. For each patient, brain parenchyma density in Hounsfield units (HUs) was measured in 10 selected slices from the supratentorial region. In each slice, different regions of interest (ROIs), including and excluding the cortical parenchyma, were defined. The injured hemisphere, the contralateral hemisphere, and the absolute differences between them were analyzed. The outcome was evaluated using the Glasgow Outcome Scale-Extended at 1 year after TBI. RESULTS Fifteen patients (38.5%) had a favorable outcome. Collected demographic, clinical, and radiographic data did not show significant differences between favorable and unfavorable outcomes. In contrast, the densitometric analysis demonstrated that greater absolute differences between both hemispheres were associated with poor outcome. These differences were detected along the supratentorial region, but were greater at the high convexity level. Moreover, these HU differences were far more marked at the cortical parenchyma. It was also detected that these differences were more prone to ischemic and/or edematous insults than to hyperemic changes. Age was significantly correlated with the side-to-side HU differences in patients with unfavorable outcome. CONCLUSIONS The densitometric analysis is a promising prognostic tool in patients diagnosed with ASDH. The supplementary prognostic information provided by the densitometric analysis should be evaluated in future studies.
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Abstract
OBJECTIVES Lateral displacement and impaired cerebral autoregulation are associated with worse outcomes following acute brain injury, but their effect on long-term clinical outcomes remains unclear. We assessed the relationship between lateral displacement, disturbances to cerebral autoregulation, and clinical outcomes in acutely comatose patients. DESIGN Retrospective analysis of prospectively collected data. SETTING Neurocritical care unit of the Johns Hopkins Hospital. PATIENTS Acutely comatose patients (Glasgow Coma Score ≤ 8). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cerebral oximetry index, derived from near-infrared spectroscopy multimodal monitoring, was used to evaluate cerebral autoregulation. Associations between lateral brain displacement, global cerebral autoregulation, and interhemispheric cerebral autoregulation asymmetry were assessed using mixed random effects models with random intercept. Patients were grouped by functional outcome, determined by the modified Rankin Scale. Associations between outcome group, lateral displacement, and cerebral oximetry index were assessed using multivariate linear regression. Increasing lateral brain displacement was associated with worsening global cerebral autoregulation (p = 0.01 septum; p = 0.05 pineal) and cerebral autoregulation asymmetry (both p < 0.001). Maximum lateral displacement during the first 3 days of coma was significantly different between functional outcome groups at hospital discharge (p = 0.019 pineal; p = 0.008 septum), 3 months (p = 0.026; p = 0.007), 6 months (p = 0.018; p = 0.010), and 12 months (p = 0.022; p = 0.012). Global cerebral oximetry index was associated with functional outcomes at 3 months (p = 0.019) and 6 months (p = 0.013). CONCLUSIONS During the first 3 days of acute coma, increasing lateral brain displacement is associated with worsening global cerebral autoregulation and cerebral autoregulation asymmetry, and poor long-term clinical outcomes in acutely comatose patients. The impact of acute interventions on outcome needs to be explored.
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Hong JH, Jeon I, Seo Y, Kim SH, Yu D. Radiographic predictors of clinical outcome in traumatic brain injury after decompressive craniectomy. Acta Neurochir (Wien) 2021; 163:1371-1381. [PMID: 33404876 DOI: 10.1007/s00701-020-04679-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 12/11/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Primary decompressive craniectomy (DC) is considered for traumatic brain injury (TBI) patients with clinical deterioration, presenting large amounts of high-density lesions on computed tomography (CT). Postoperative CT findings may be suitable for prognostic evaluation. This study evaluated the radiographic predictors of clinical outcome and survival using pre- and postoperative CT scans of such patients. METHODS We enrolled 150 patients with moderate to severe TBI who underwent primary DC. They were divided into two groups based on the 6-month postoperative Glasgow Outcome Scale Extended scores (1-4, unfavorable; 5-8, favorable). Radiographic parameters, including hemorrhage type, location, presence of skull fracture, midline shifting, hemispheric diameter, effacement of cisterns, parenchymal hypodensity, and craniectomy size, were reviewed. Stepwise logistic regression analysis was used to identify the prognostic factors of clinical outcome and 6-month mortality. RESULTS Multivariable logistic regression analysis revealed that age (odds ratio [OR] = 1.09; 95% confidence interval [CI] 1.032-1.151; p = 0.002), postoperative low density (OR = 12.58; 95% CI 1.247-126.829; p = 0.032), and postoperative effacement of the ambient cistern (OR = 14.52; 95% CI 2.234-94.351; p = 0.005) and the crural cistern (OR = 4.90; 95% CI 1.359-17.678; p = 0.015) were associated with unfavorable outcomes. Postoperative effacement of the crural cistern was the strongest predictor of 6-month mortality (OR = 8.93; 95% CI 2.747-29.054; p = 0.000). CONCLUSIONS Hemispheric hypodensity and effacement of the crural and ambient cisterns on postoperative CT after primary DC seems to associate with poor outcome in patients with TBI.
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Affiliation(s)
- Jung Ho Hong
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Ikchan Jeon
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Youngbeom Seo
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Seong Ho Kim
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea
| | - Dongwoo Yu
- Department of Neurosurgery, Yeungnam University Hospital, Yeungnam University College of Medicine, 170, Hyeonchung street, Nam-Gu, Daegu, 42415, South Korea.
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Hooper SM, Dunnmon JA, Lungren MP, Mastrodicasa D, Rubin DL, Ré C, Wang A, Patel BN. Impact of Upstream Medical Image Processing on Downstream Performance of a Head CT Triage Neural Network. Radiol Artif Intell 2021; 3:e200229. [PMID: 34350412 PMCID: PMC8328108 DOI: 10.1148/ryai.2021200229] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 04/01/2021] [Accepted: 04/08/2021] [Indexed: 01/17/2023]
Abstract
PURPOSE To develop a convolutional neural network (CNN) to triage head CT (HCT) studies and investigate the effect of upstream medical image processing on the CNN's performance. MATERIALS AND METHODS A total of 9776 HCT studies were retrospectively collected from 2001 through 2014, and a CNN was trained to triage them as normal or abnormal. CNN performance was evaluated on a held-out test set, assessing triage performance and sensitivity to 20 disorders to assess differential model performance, with 7856 CT studies in the training set, 936 in the validation set, and 984 in the test set. This CNN was used to understand how the upstream imaging chain affects CNN performance by evaluating performance after altering three variables: image acquisition by reducing the number of x-ray projections, image reconstruction by inputting sinogram data into the CNN, and image preprocessing. To evaluate performance, the DeLong test was used to assess differences in the area under the receiver operating characteristic curve (AUROC), and the McNemar test was used to compare sensitivities. RESULTS The CNN achieved a mean AUROC of 0.84 (95% CI: 0.83, 0.84) in discriminating normal and abnormal HCT studies. The number of x-ray projections could be reduced by 16 times and the raw sensor data could be input into the CNN with no statistically significant difference in classification performance. Additionally, CT windowing consistently improved CNN performance, increasing the mean triage AUROC by 0.07 points. CONCLUSION A CNN was developed to triage HCT studies, which may help streamline image evaluation, and the means by which upstream image acquisition, reconstruction, and preprocessing affect downstream CNN performance was investigated, bringing focus to this important part of the imaging chain.Keywords Head CT, Automated Triage, Deep Learning, Sinogram, DatasetSupplemental material is available for this article.© RSNA, 2021.
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KIYOHIRA M, SUEHIRO E, SHINOYAMA M, FUJIYAMA Y, HAJI K, SUZUKI M. Combined Strategy of Burr Hole Surgery and Elective Craniotomy under Intracranial Pressure Monitoring for Severe Acute Subdural Hematoma. Neurol Med Chir (Tokyo) 2021; 61:253-259. [PMID: 33597319 PMCID: PMC8048118 DOI: 10.2176/nmc.oa.2020-0266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 11/25/2020] [Indexed: 11/24/2022] Open
Abstract
Burr hole surgery in the emergency room can be lifesaving for patients with acute subdural hematoma (ASDH). In the first part of this study, a strategy of combined burr hole surgery, a period of intracranial pressure (ICP) monitoring, and then craniotomy was examined for safe and effective treatment of ASDH. Since 2012, 16 patients with severe ASDH with indications for burr hole surgery were admitted to Kenwakai Otemachi Hospital. From 2012 to 2016, craniotomy was performed immediately after burr hole surgery (emergency [EM] group, n = 10). From 2017, an ICP sensor was placed before burr hole surgery. After a period for correction of traumatic coagulopathy, craniotomy was performed when ICP increased (elective [EL] group, n = 6). Patient background, bleeding tendency, intraoperative blood transfusion, and outcomes were compared between the groups. In the second part of the study, ICP was measured before and after burr hole surgery in seven patients (including two of the six in the EL group) to assess the effect of this surgery. Activated partial thromboplastin time (APTT) and prothrombin time-international normalized ratio (PT-INR) were significantly prolonged after craniotomy in the EM group, but not in the EL group, and the EM group tended to require a higher intraoperative transfusion volume. The rate of good outcomes was significantly higher in the EL group, and ICP was significantly decreased after burr hole surgery. These results suggest the value of burr hole surgery followed by ICP monitoring in patients with severe ASDH. Craniotomy can be performed safely using this method, and this may contribute to improved outcomes.
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Affiliation(s)
- Miwa KIYOHIRA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Eiichi SUEHIRO
- Department of Neurosurgery, International University of Health and Welfare, School of Medicine, Narita, Chiba, Japan
| | - Mizuya SHINOYAMA
- Department of Neurosurgery, Kenwakai Otemachi Hospital, Kitakyushu, Fukuoka, Japan
| | - Yuichi FUJIYAMA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
- Department of Neurosurgery, Shinyurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Kohei HAJI
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
| | - Michiyasu SUZUKI
- Department of Neurosurgery, Shinyurigaoka General Hospital, Kawasaki, Kanagawa, Japan
- Department of Advanced ThermoNeuroBiology, Yamaguchi University School of Medicine, Ube, Yamaguchi, Japan
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Nael K, Gibson E, Yang C, Ceccaldi P, Yoo Y, Das J, Doshi A, Georgescu B, Janardhanan N, Odry B, Nadar M, Bush M, Re TJ, Huwer S, Josan S, von Busch H, Meyer H, Mendelson D, Drayer BP, Comaniciu D, Fayad ZA. Automated detection of critical findings in multi-parametric brain MRI using a system of 3D neural networks. Sci Rep 2021; 11:6876. [PMID: 33767226 PMCID: PMC7994311 DOI: 10.1038/s41598-021-86022-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 03/08/2021] [Indexed: 01/22/2023] Open
Abstract
With the rapid growth and increasing use of brain MRI, there is an interest in automated image classification to aid human interpretation and improve workflow. We aimed to train a deep convolutional neural network and assess its performance in identifying abnormal brain MRIs and critical intracranial findings including acute infarction, acute hemorrhage and mass effect. A total of 13,215 clinical brain MRI studies were categorized to training (74%), validation (9%), internal testing (8%) and external testing (8%) datasets. Up to eight contrasts were included from each brain MRI and each image volume was reformatted to common resolution to accommodate for differences between scanners. Following reviewing the radiology reports, three neuroradiologists assigned each study to abnormal vs normal, and identified three critical findings including acute infarction, acute hemorrhage, and mass effect. A deep convolutional neural network was constructed by a combination of localization feature extraction (LFE) modules and global classifiers to identify the presence of 4 variables in brain MRIs including abnormal, acute infarction, acute hemorrhage and mass effect. Training, validation and testing sets were randomly defined on a patient basis. Training was performed on 9845 studies using balanced sampling to address class imbalance. Receiver operating characteristic (ROC) analysis was performed. The ROC analysis of our models for 1050 studies within our internal test data showed AUC/sensitivity/specificity of 0.91/83%/86% for normal versus abnormal brain MRI, 0.95/92%/88% for acute infarction, 0.90/89%/81% for acute hemorrhage, and 0.93/93%/85% for mass effect. For 1072 studies within our external test data, it showed AUC/sensitivity/specificity of 0.88/80%/80% for normal versus abnormal brain MRI, 0.97/90%/97% for acute infarction, 0.83/72%/88% for acute hemorrhage, and 0.87/79%/81% for mass effect. Our proposed deep convolutional network can accurately identify abnormal and critical intracranial findings on individual brain MRIs, while addressing the fact that some MR contrasts might not be available in individual studies.
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Affiliation(s)
- Kambiz Nael
- Department of Radiological Sciences, David Geffen School of Medicine at University of California Los Angeles, 757 Westwood Plaza, Suite 1621, Los Angeles, CA, 90095-7532, USA.
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Eli Gibson
- Digital Technology and Innovation, Siemens Healthineers, Princeton, USA
| | - Chen Yang
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Pascal Ceccaldi
- Digital Technology and Innovation, Siemens Healthineers, Princeton, USA
| | - Youngjin Yoo
- Digital Technology and Innovation, Siemens Healthineers, Princeton, USA
| | - Jyotipriya Das
- Digital Technology and Innovation, Siemens Healthineers, Princeton, USA
| | - Amish Doshi
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Bogdan Georgescu
- Digital Technology and Innovation, Siemens Healthineers, Princeton, USA
| | | | - Benjamin Odry
- AI for Clinical Analytics, Covera Health, New York, NY, USA
| | - Mariappan Nadar
- Digital Technology and Innovation, Siemens Healthineers, Princeton, USA
| | - Michael Bush
- Magnetic Resonance, Siemens Healthineers, New York, USA
| | - Thomas J Re
- Digital Technology and Innovation, Siemens Healthineers, Princeton, USA
| | - Stefan Huwer
- Magnetic Resonance, Siemens Healthineers, Erlangen, Germany
| | - Sonal Josan
- Digital Health, Siemens Healthineers, Erlangen, Germany
| | | | - Heiko Meyer
- Magnetic Resonance, Siemens Healthineers, Erlangen, Germany
| | - David Mendelson
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Burton P Drayer
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Dorin Comaniciu
- Digital Technology and Innovation, Siemens Healthineers, Princeton, USA
| | - Zahi A Fayad
- Department of Diagnostic, Molecular and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, USA
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Toledo JA, Namias R, Milano MJ. A Novel Automated Calculation of Basal Cistern Effacement Status on Computed Tomographic Imaging in Traumatic Brain Injury. Cureus 2021; 13:e13144. [PMID: 33692917 PMCID: PMC7937044 DOI: 10.7759/cureus.13144] [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] [Indexed: 11/06/2022] Open
Abstract
Introduction To predict patient outcomes in traumatic brain injury (TBI) lesions, various scores have been proposed, which use objective assessments. These scores, however, rely on the observer's ability to determine them. This study presents a comprehensive, reproducible, and more anatomically stratified objective measurement of the degree of basal cistern effacement in brain computed tomographic (CT) scan images. Methods Patients with TBI admitted from August 2015 to February 2016 were included. The control group consisted of non-trauma patients, who had normal brain CT scans. The images were analyzed by an automated volumetric compression ratio (CR) defined as the volume ratio between the parenchymal tissue and the cerebrospinal fluid (CSF) in the basal cisterns. This value was compared with the TBI severity recorded at each patient's admission and a consensus score of the basal cisterns' degree of effacement by manual analysis. Results Seventy-three TBI patients were admitted. The mean admission Glasow Coma Scale (GCS) score was 9. In the non-TBI control group, 29 patients were enrolled. The average kappa value for the inter-observer agreement was 0.583. The CR had an inverse linear relationship with the severity of the TBI and the degree of effacement of the basal cisterns. The correlation between the CR value in the midbrain and the specialists' consensus determination was statistically significant (p < 0.01). The CR also showed a difference between the TBI and the control groups (p 0.0001). Conclusions The automated CR is a useful objective variable to determine the degree of basal cistern effacement. The proposed ratio has a good correlation with the classical basal cistern effacement classification and TBI severity.
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Affiliation(s)
- Javier A Toledo
- Neurosurgery, Clemente Alvarez Hospital, Rosario, ARG.,Neurosurgery Department, Sanatorio Parque - Grupo Oroño, Rosario, ARG
| | - Rafael Namias
- Algorithm Research Department, Brainomix, Oxford, GBR
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Chen CC, Chen CPC, Chen CH, Hsieh YW, Chung CY, Liao CH. Predictors of In-Hospital Mortality for School-Aged Children with Severe Traumatic Brain Injury. Brain Sci 2021; 11:136. [PMID: 33494346 PMCID: PMC7912264 DOI: 10.3390/brainsci11020136] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/15/2021] [Accepted: 01/17/2021] [Indexed: 11/29/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of mortality in children. There are few studies focused on school-aged children with TBI. We conducted this study to identify the early predictors of in-hospital mortality in school-aged children with severe TBI. In this 10 year observational cohort study, a total of 550 children aged 7-18 years with TBI were enrolled. Compared with mild/moderate TBI, children with severe TBI were older; more commonly had injury mechanisms of traffic accidents; and more neuroimage findings of subarachnoid hemorrhage (SAH), subdural hemorrhage (SDH), parenchymal hemorrhage, cerebral edema, and less epidural hemorrhage (EDH). The in-hospital mortality rate of children with severe TBI in our study was 23%. Multivariate analysis showed that falls, being struck by objects, motor component of Glasgow coma scale (mGCS), early coagulopathy, and SAH were independent predictors of in-hospital mortality. We concluded that school-aged children with severe TBI had a high mortality rate. Clinical characteristics including injury mechanisms of falls and being struck, a lower initial mGCS, early coagulopathy, and SAH are predictive of in-hospital mortality.
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Affiliation(s)
- Chih-Chi Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan; (C.-C.C.); (C.P.C.C.); (C.-H.C.); (C.-Y.C.)
| | - Carl P. C. Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan; (C.-C.C.); (C.P.C.C.); (C.-H.C.); (C.-Y.C.)
| | - Chien-Hung Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan; (C.-C.C.); (C.P.C.C.); (C.-H.C.); (C.-Y.C.)
| | - Yu-Wei Hsieh
- Department of Occupational Therapy and Graduate Institute of Behavioral Sciences, School of Medicine, Chang Gung University, 259, Sec1, WenHua First Road, Taoyuan 333, Taiwan;
- Healthy Aging Research Center, Chang Gung University, 259, Sec1, WenHua First Road, Taoyuan 333, Taiwan
| | - Chia-Ying Chung
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan; (C.-C.C.); (C.P.C.C.); (C.-H.C.); (C.-Y.C.)
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, School of Medicine, Chang Gung University, 5 Fuhsing St., Taoyuan 333, Taiwan
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Gaitanidis A, Breen KA, Maurer LR, Saillant NN, Kaafarani HMA, Velmahos GC, Mendoza AE. Systolic Blood Pressure <110 mm Hg as a Threshold of Hypotension in Patients with Isolated Traumatic Brain Injuries. J Neurotrauma 2020; 38:879-885. [PMID: 33107386 DOI: 10.1089/neu.2020.7358] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Hypotension is a known risk factor for poor neurologic outcomes after traumatic brain injury (TBI). Current guidelines suggest that higher systolic blood pressure (SBP) thresholds likely confer a mortality benefit. However, there is no consensus on the ideal perfusion pressure among different age groups (i.e., recommended SBP ≥100 mm Hg for patients age 50-69 years; ≥ 110 mm Hg for all other adults). We hypothesize that admission SBP ≥110 mm Hg will be associated with improved outcomes regardless of age group. A retrospective database review of the 2010-2016 Trauma Quality Improvement Program database was performed for adults (≥ 18 years) with isolated moderate-to-severe TBIs (head Abbreviated Injury Scale [AIS] ≥3; all other AIS <3). Sub-analyses were performed after dividing patients by SBP and age; comparison groups were matched with propensity score matching. Primary outcomes were early (6 h, 12 h, and 1 day) and overall in-hospital mortality. Overall, 154,725 patients met the inclusion criteria (mean age 62.8 ± 19.8 years, 89,431 [57.8%] males, Injury Severity Score13.9 ± 6.8). Multi-variate logistic regression showed that the risk of in-hospital mortality decreased with increasing SBP, plateauing at 110 mm Hg. Among patients of all ages, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-129 vs. 90-109 mm Hg: 12 h 0.4% vs. 0.8%, p = 0.001; 1 day 0.8% vs. 1.4%, p = 0.004; overall 3.2% vs. 4.9%, p < 0.001). Among patients age 50-69 years, SBP ≥110 mm Hg was associated with improved mortality (SBP 110-119 vs. 100-109 mm Hg: 12 h 0.3% vs. 0.9%, p = 0.018; 1 day 0.5% vs. 1.5%, p = 0.007; overall 2.7% vs. 4.3%, p = 0.015). In conclusion, SBP ≥110 mm Hg is associated with lower in-hospital mortality in adult patients with isolated TBIs, including patients age 50-69 years. SBP <110 mm Hg should be used to define hypotension in adult patients of all ages.
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Affiliation(s)
- Apostolos Gaitanidis
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kerry A Breen
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lydia R Maurer
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Noelle N Saillant
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, Massachusetts, USA
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Weppner J, Ide W, Tu J, Boomgaardt J, Chang A, Suskauer S. Prognostication and Determinants of Outcome in Adults and Children with Moderate-to-Severe Traumatic Brain Injury. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00298-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hakim SM, Abdellatif AA, Ali MI, Ammar MA. Reliability of transcranial sonography for assessment of brain midline shift in adult neurocritical patients: a systematic review and meta-analysis. Minerva Anestesiol 2020; 87:467-475. [PMID: 33054015 DOI: 10.23736/s0375-9393.20.14624-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
INTRODUCTION The aim of this systematic review and meta-analysis was to determine the reliability of transcranial sonography as an alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. EVIDENCE AQUISITION The PubMed, EMBASE, Cochrane Library, Scopus and Web of Science databases were searched. Original studies evaluating brain midline shift in adult neurocritical patients using both transcranial sonography and computed tomography were eligible. Primary outcome measure was concordance between both methods as quantified in terms of concordance correlation coefficient. Secondary outcome measure was limits of agreement, defined as mean difference between sonography and computed tomography plus and minus 1.96 standard deviations. EVIDENCE SYNTHESIS Twelve studies (574 patients, 689 examinations) were eligible. Ten studies (416 patients, 492 examinations) provided adequate data for evaluation of concordance. Pooling of effect sizes showed strong concordance between both methods (concordance correlation coefficient, 0.91; 95% CI, 0.87 to 0.94). Two missing studies were imputed and effect size was adjusted to 0.88 (95% CI, 0.81 to 0.93). Nine studies (442 patients, 571 examinations) provided adequate data for estimation of limits of agreement. Pooling of effect sizes showed a bias of -0.53 mm (95% limits of agreement, -1.22 to 0.16 mm). Four missing studies were imputed and bias was adjusted to -0.68 mm (95% limits of agreement, -1.31 to -0.04 mm). CONCLUSIONS Transcranial sonography may serve as reliable alternative to computed tomography for evaluation of brain midline shift in adult neurocritical patients. Both methods have strong concordance with acceptably narrow limits of agreement.
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Affiliation(s)
- Sameh M Hakim
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt -
| | - Ayman A Abdellatif
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohammad I Ali
- Department of Intensive Care, King Abdulaziz Hospital, Al-Jouf, Saudi Arabia
| | - Mona A Ammar
- Department of Anesthesiology and Intensive Care, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Choudhary A, Kaushik K, Bhaskar SN, Gupta LN, Sharma R, Varshney R. Correlation of Initial Computed Tomography Findings with Outcomes of Patients with Acute Subdural Hematoma: A Prospective Study. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Introduction In modern emergency service systems, patients are often treated with sedation, intubation, and ventilation at the accident site. But neurosurgical assessment before all these emergency services is important. Thus, this study was designed to investigate the relationships between various parameters of initial CT scan findings and the outcomes of the patients.
Methodology A total of 56 adult patients of traumatic acute subdural hematoma (SDH) whose computed tomography (CT) scan was performed within 8 hours of injury were recruited. The patients with prolonged hypotension, open head injury or depressed skull fracture, bilateral side acute SDH, or contusions/hematoma/extradural hematoma on the contralateral side were excluded. Six separate CT findings were analyzed and recorded, including hematoma, midline shift, subarachnoid hemorrhage (SAH), presence of basal cistern obliteration (BCO), intraparenchymal hematoma/contusion in the same hemisphere, and presence of effacement of the sulcal spaces, and were followed up for three months for outcome analysis.
Results The overall mortality and functional recovery rate were 27 and 50%, respectively. The patients with obliterated basal cisterns and the presence of underlying SAH in patients with acute SDH had statistically significant poorer outcomes as compared with others. However, the extent of midline shift, SDH thickness, and the presence of underlying contusions and sulcal effacement on initial CT scan showed no statistically significant correlation with patients’ outcomes.
Conclusions BCO and presence of subarchnoid hemorrhage underlying acute SDH on the earliest scan in head injury patients signify the severity of brain parenchymal injury. Along with the initial Glasgow Coma Scale score after resuscitation, these two factors should be considered as the most significant ones for predicting the outcomes in traumatic acute SDH patients.
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Affiliation(s)
- Ajay Choudhary
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Kaviraj Kaushik
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Surya Narayanan Bhaskar
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Laxmi Narayan Gupta
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Rajesh Sharma
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
| | - Rahul Varshney
- Department of Neurosurgery, Atal Bihari Vajpayee Institute of Medical Sciences, Ram Manohar Lohia Hospital, New Delhi, India
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Surgical outcomes in traumatic brain injuries with bilateral mass occupying lesions. Analysis of prognostic factors. Clin Neurol Neurosurg 2020; 196:106017. [PMID: 32619900 DOI: 10.1016/j.clineuro.2020.106017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 06/10/2020] [Accepted: 06/12/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Traumatic brain injury is a silent epidemic with major impacts on national productivity as it affects the economically productive age group. Bilateral injuries are usually severe with no clearly defined predictors of outcome as per current available literature. METHODS We retrospectively assessed 102 consecutive cases of post traumatic intracranial mass lesions operated bilaterally, either simultaneously or sequentially, between January 2011 and April 2019. The primary and secondary end points of the study were to assess mortality and GCS at discharge respectively. RESULTS The cohort included 102 patients. 91(89.2 %) were males, mean age was 40(±13.6) years. Median GCS at presentation was 9 with 47(46.07 %) having moderate head injury. EDH with contusion was seen in 38(37.3 %), SDH with contusion in 24(23.5 %) and 4 patients (3.9 %) had EDH, SDH and contusion. On univariate analysis, female gender(p = 0.001), poor GCS at presentation(p < 0.001), higher Rotterdam grade on initial CT scan(p < 0.001), need for blood transfusions(p = 0.026) and intraoperative hypotension(p = 0.007) were associated with significantly higher mortality. On multivariate analysis female gender(p = 0.034), poor GCS(p = 0.026) and worse Rotterdam score(p = 0.038) were associated with mortality. Among the subgroup of survivors, GCS at presentation(p < 0.001), Rotterdam grading(p = 0.003), time to surgery after trauma(p = 0.032), duration of hospital stay(<0.001), intraoperative brain bulge(p=.003) and craniotomy instead of craniectomy(p = 0.001) were associated with clinical outcome at discharge. CONCLUSION Traumatic brain injuries with bilateral mass lesions requiring surgery have been rarely reported. In this study we have elucidated management strategies and have further studied the factors influencing mortality and clinical outcome. Careful considerations are required in decision making in such cases. Larger multicentric studies would throw more light on outcomes of this rare variety of traumatic brain injury.
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Canac N, Jalaleddini K, Thorpe SG, Thibeault CM, Hamilton RB. Review: pathophysiology of intracranial hypertension and noninvasive intracranial pressure monitoring. Fluids Barriers CNS 2020; 17:40. [PMID: 32576216 PMCID: PMC7310456 DOI: 10.1186/s12987-020-00201-8] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/11/2020] [Indexed: 12/30/2022] Open
Abstract
Measurement of intracranial pressure (ICP) is crucial in the management of many neurological conditions. However, due to the invasiveness, high cost, and required expertise of available ICP monitoring techniques, many patients who could benefit from ICP monitoring do not receive it. As a result, there has been a substantial effort to explore and develop novel noninvasive ICP monitoring techniques to improve the overall clinical care of patients who may be suffering from ICP disorders. This review attempts to summarize the general pathophysiology of ICP, discuss the importance and current state of ICP monitoring, and describe the many methods that have been proposed for noninvasive ICP monitoring. These noninvasive methods can be broken down into four major categories: fluid dynamic, otic, ophthalmic, and electrophysiologic. Each category is discussed in detail along with its associated techniques and their advantages, disadvantages, and reported accuracy. A particular emphasis in this review will be dedicated to methods based on the use of transcranial Doppler ultrasound. At present, it appears that the available noninvasive methods are either not sufficiently accurate, reliable, or robust enough for widespread clinical adoption or require additional independent validation. However, several methods appear promising and through additional study and clinical validation, could eventually make their way into clinical practice.
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Rafay M, Gulzar F, Iqbal N, Sharif S. Prognostic computed tomography Scores in traumatic brain injury. Clin Neurol Neurosurg 2020; 195:105957. [PMID: 32485552 DOI: 10.1016/j.clineuro.2020.105957] [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: 04/27/2020] [Revised: 05/21/2020] [Accepted: 05/22/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Traumatic brain injuries represent a significant cause of morbidity and mortality worldwide and road traffic crashes account for a significant proportion of these injuries. It is one of the leading causes of death, especially among young adults, and, according to the World Health Organization, this will surpass many diseases as the major cause of death and disability by the year 2020 and lifelong disability is common in those who survive. It is also known as the silent epidemic. Many CT scan scoring systems for brain injury have been developed but none of them are validated. These scores are based on structural findings of CT scan to predict the prognosis. Marshall and Rotterdam are the two most widely used scoring systems. METHOD This was an observational study with prospectively collected data. 903 consecutive patients with TBI. This study aimed to compare the Helsinki CT scoring system with the Rotterdam scoring system to find out the better score for the prognostic purpose by using the Glasgow outcome score. RESULTS Helsinki CT scoring system was found to be the most accurate score among the others in predicting the outcome of the patient based on morphological findings in CT scan. These scores also guided us regarding the treatment plan and patients with the good prognostic outcome are usually treated aggressively. Also these scores guide clinicians whether to opt for a conservative approach or any intervention. CONCLUSION In this study we compared, Rotterdam vs. Helsinki CT Scoring System. We observed that the Helsinki score was a better outcome predictor for TBI than the Rotterdam score and can be used as a single validated score in predicting outcome and guiding the treatment.
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Affiliation(s)
- Muhammad Rafay
- Department of Neurosurgery, Liaquat National Hospital, National Stadium Road, Karachi, 74800, Pakistan.
| | - Farhan Gulzar
- Department of Neurosurgery, Liaquat National Hospital, National Stadium Road, Karachi, 74800, Pakistan.
| | - Noorulain Iqbal
- Department of Neurosurgery, Liaquat National Hospital, National Stadium Road, Karachi, 74800, Pakistan.
| | - Salman Sharif
- Department of Neurosurgery, Liaquat National Hospital, National Stadium Road, Karachi, 74800, Pakistan.
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Lietke S, Zausinger S, Patzig M, Holtmanspötter M, Kunz M. CT-Based Classification of Acute Cerebral Edema: Association with Intracranial Pressure and Outcome. J Neuroimaging 2020; 30:640-647. [PMID: 32462690 DOI: 10.1111/jon.12736] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 04/26/2020] [Accepted: 05/12/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Brain edema after acute cerebral lesions may lead to raised intracranial pressure (ICP) and worsen outcome. Notwithstanding, no CT-based scoring system to quantify edema formation exists. This retrospective correlative analysis aimed to establish a valid and definite CT score quantifying brain edema after common acute cerebral lesions. METHODS A total of 169 CT investigations in 60 patients were analyzed: traumatic brain injury (TBI; n = 47), subarachnoid hemorrhage (SAH; n = 70), intracerebral hemorrhage (ICH; n = 42), and ischemic stroke (n = 10). Edema formation was classified as 0: no edema, 1: focal edema confined to 1 lobe, 2: unilateral edema > 1 lobe, 3: bilateral edema, 4: global edema with disappearance of sulcal relief, and 5: global edema with basal cisterns effacement. ICP and Glasgow Outcome Score (GOS) were correlated to edema formation. RESULTS Median ICP values were 12.0, 14.0, 14.9, 18.2, and 25.9 mm Hg in grades 1-5, respectively. Edema grading significantly correlated with ICP (r = .51; P < .0001) in focal and global cerebral edema, particularly in patients with TBI, SAH, and ICH (r = .5, P < .001; r = .5; P < .0001; r = .6, P < .0001, respectively). At discharge, 23.7% of patients achieved a GOS of 5 or 4, 65.0% reached a GOS of 3 or 2, and 11.9% died (GOS 1). CT-score of cerebral edema in all patients correlated with outcome (r = -.3, P = .046). CONCLUSION The proposed CT-based grading of extent of cerebral edema significantly correlated with ICP and outcome in TBI, SAH, and ICH patients and might be helpful for standardized description of CT-images and as parameter for clinical studies, for example, measuring effects of antiedematous therapies.
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Affiliation(s)
- Stefanie Lietke
- Department of Neurosurgery, Ludwigs-Maximilians University, Munich, Germany
| | - Stefan Zausinger
- Department of Neurosurgery, Ludwigs-Maximilians University, Munich, Germany
| | - Maximilian Patzig
- Institute for Neuroradiology, Ludwig-Maximilians University, Munich, Germany
| | - Markus Holtmanspötter
- Institute for Neuroradiology, Ludwig-Maximilians University, Munich, Germany.,Nuremberg Hospital, Neuroradiology, Paracelsus Medical University, Nürnberg, Germany
| | - Mathias Kunz
- Department of Neurosurgery, Ludwigs-Maximilians University, Munich, Germany
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Comparative Radiographic Factors Predicting Functional Outcome After Decompressive Craniectomy in Severe Traumatic Brain Injury. World Neurosurg 2020; 138:e876-e882. [PMID: 32251815 DOI: 10.1016/j.wneu.2020.03.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 03/19/2020] [Accepted: 03/20/2020] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Decompressive craniectomy (DC) is a last-tier therapy in the treatment of raised intracranial pressure after traumatic brain injury (TBI). We report the association of comparative radiographic factors in predicting functional outcomes after DC in patients with severe TBI. METHODS A retrospective analysis of a prospectively maintained database of cases between 2015 and 2018 at an academic tertiary care hospital was carried out. Univariate and multivariable regression analyses were performed for an array of comparative radiographic variables (pre- and post-DC) in relationship to functional outcome according to Glasgow Outcome Scale Extended (GOSE) at 180 days. GOSE was further dichotomized into favorable (GOSE:5-8) and unfavorable (GOSE:0-4) functional outcomes. All associations were reported as odds ratio (OR) with 95% confidence interval (CI). RESULTS Statistical analysis included a cohort of 43 patients with a median age of 30.5 years (range: 18-62 years). The median GOSE at 180 days was 7. Multivariable regression analysis after adjusting for confounding variables (age, sex, comorbidities, site of surgery and size of decompression) showed that comparative radiographic findings of midline shift (MLS) > 10 mm (OR 3.2 (95% CI 1.25-8.04); P = 0.01); external cerebral herniation (ECH) > 2.5 cm (OR 2.5 [95% CI 1.18-5.2]; P = 0.02); and effacement of basal cisterns (OR 3.9 [95%CI 1.1-13.9]; P = 0.03), were significant independent predictors of poor functional outcome at 180 days after DC for severe TBI. However, the presence of infarction (OR 2.7 [95%CI 0.43-17.2]; P = 0.28) and absence of gray-white matter differentiation (OR 0.18 [95%CI 0.03-1.2]; P = 0.07) did not reach statistical significance. CONCLUSIONS The comparative radiographic findings that include MLS > 10mm, ECH > 2.5cm, and effacement of basal cisterns are predictive of poor functional outcome in severe TBI.
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Zusman BE, Kochanek PM, Jha RM. Cerebral Edema in Traumatic Brain Injury: a Historical Framework for Current Therapy. Curr Treat Options Neurol 2020; 22:9. [PMID: 34177248 PMCID: PMC8223756 DOI: 10.1007/s11940-020-0614-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1. SUMMARY This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, UPMC, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
| | - Ruchira M. Jha
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jha RM, Bell J, Citerio G, Hemphill JC, Kimberly WT, Narayan RK, Sahuquillo J, Sheth KN, Simard JM. Role of Sulfonylurea Receptor 1 and Glibenclamide in Traumatic Brain Injury: A Review of the Evidence. Int J Mol Sci 2020; 21:E409. [PMID: 31936452 PMCID: PMC7013742 DOI: 10.3390/ijms21020409] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 12/28/2019] [Accepted: 01/03/2020] [Indexed: 02/07/2023] Open
Abstract
Cerebral edema and contusion expansion are major determinants of morbidity and mortality after TBI. Current treatment options are reactive, suboptimal and associated with significant side effects. First discovered in models of focal cerebral ischemia, there is increasing evidence that the sulfonylurea receptor 1 (SUR1)-Transient receptor potential melastatin 4 (TRPM4) channel plays a key role in these critical secondary injury processes after TBI. Targeted SUR1-TRPM4 channel inhibition with glibenclamide has been shown to reduce edema and progression of hemorrhage, particularly in preclinical models of contusional TBI. Results from small clinical trials evaluating glibenclamide in TBI have been encouraging. A Phase-2 study evaluating the safety and efficacy of intravenous glibenclamide (BIIB093) in brain contusion is actively enrolling subjects. In this comprehensive narrative review, we summarize the molecular basis of SUR1-TRPM4 related pathology and discuss TBI-specific expression patterns, biomarker potential, genetic variation, preclinical experiments, and clinical studies evaluating the utility of treatment with glibenclamide in this disease.
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Affiliation(s)
- Ruchira M. Jha
- Departments of Critical Care Medicine, Neurology, Neurological Surgery, Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA 15201, USA
| | | | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, 20121 Milan, Italy;
- Anaesthesia and Intensive Care, San Gerardo and Desio Hospitals, ASST-Monza, 20900 Monza, Italy
| | - J. Claude Hemphill
- Department of Neurology, University of California, San Francisco, CA 94110, USA;
| | - W. Taylor Kimberly
- Division of Neurocritical Care and Center for Genomic Medicine, Department of Neurology, Massachusetts General Hospital, Boston, MA 02108, USA;
| | - Raj K. Narayan
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY 11030, USA;
| | - Juan Sahuquillo
- Neurotrauma and Neurosurgery Research Unit (UNINN), Vall d′Hebron Research Institute (VHIR), 08001 Barcelona, Spain;
- Department of Neurosurgery, Universitat Autònoma de Barcelona (UAB), 08001 Barcelona, Spain
- Department of Neurosurgery, Vall d′Hebron University Hospital, 08001 Barcelona, Spain
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT 06501, USA;
| | - J. Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Mokolane NS, Minne C, Dehnavi A. Prevalence and pattern of basal skull fracture in head injury patients in an academic hospital. SA J Radiol 2019; 23:1677. [PMID: 31754528 PMCID: PMC6837784 DOI: 10.4102/sajr.v23i1.1677] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/20/2019] [Indexed: 11/05/2022] Open
Abstract
Background Basal skull fractures (BSFs) have been reported to be a major cause of morbidity and mortality in the literature, particularly in young male patients. However, there are limited data available on the aetiology, prevalence and patterns of such observed in South Africa. Objectives To evaluate the prevalence and pattern of BSF in head injury patients referred to Dr George Mukhari Academic Hospital, Gauteng, South Africa. Methods Patients of all ages with head injuries were considered for the study, and those who met the inclusion criteria were scanned using a 128-slice multidetector helical computed tomography (CT) machine after obtaining consent. Data were prospectively obtained over a 6-month period, interpreted on an advanced workstation by two readers and statistically analysed. Results The prevalence of BSF in this study was found to be 15.2%. The majority of patients (80.5%) were under 40 years old, with a male to female ratio of 3:1. The most common aetiology of BSF was assault, which accounted for 46% of cases. The middle cranial fossa was the most frequently fractured compartment, while the petrous bone was the most commonly fractured bone. There was a statistically significant association between head injury severity and BSF, and between the number of fracture lines and associated signs of BSF (p < 0.001). The sensitivity of clinical signs in predicting BSF was 31%, while specificity was 89.3% (p = 0.004). Conclusion The prevalence and pattern of BSF found were consistent with data from previously published studies, although, dissimilarly, assault was found to be the most common aetiology in this study.
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Affiliation(s)
- Ntjeke S Mokolane
- Department of Radiology, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa.,Department of Radiology, Dr George Mukhari Academic Hospital, Sefako Makgatho Health Sciences University, Ga-Rankuwa, Pretoria, South Africa
| | - Cornelia Minne
- Clinical Unit, Dr George Mukhari Academic Hospital, Ga-Rankuwa, Pretoria, South Africa
| | - Alireza Dehnavi
- Clinical Unit, Dr George Mukhari Academic Hospital, Ga-Rankuwa, Pretoria, South Africa
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50
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Puffer RC, Yue JK, Mesley M, Billigen JB, Sharpless J, Fetzick AL, Puccio A, Diaz-Arrastia R, Okonkwo DO. Long-term outcome in traumatic brain injury patients with midline shift: a secondary analysis of the Phase 3 COBRIT clinical trial. J Neurosurg 2019; 131:596-603. [PMID: 30074459 DOI: 10.3171/2018.2.jns173138] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 02/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Following traumatic brain injury (TBI), midline shift of the brain at the level of the septum pellucidum is often caused by unilateral space-occupying lesions and is associated with increased intracranial pressure and worsened morbidity and mortality. While outcome has been studied in this population, the recovery trajectory has not been reported in a large cohort of patients with TBI. The authors sought to utilize the Citicoline Brain Injury Treatment (COBRIT) trial to analyze patient recovery over time depending on degree of midline shift at presentation. METHODS Patient data from the COBRIT trial were stratified into 4 groups of midline shift, and outcome measures were analyzed at 30, 90, and 180 days postinjury. A recovery trajectory analysis was performed identifying patients with outcome measures at all 3 time points to analyze the degree of recovery based on midline shift at presentation. RESULTS There were 892, 1169, and 895 patients with adequate outcome data at 30, 90, and 180 days, respectively. Rates of favorable outcome (Glasgow Outcome Scale-Extended [GOS-E] scores 4-8) at 6 months postinjury were 87% for patients with no midline shift, 79% for patients with 1-5 mm of shift, 64% for patients with 6-10 mm of shift, and 47% for patients with > 10 mm of shift. The mean improvement from unfavorable outcome (GOS-E scores 2 and 3) to favorable outcome (GOS-E scores 4-8) from 1 month to 6 months in all groups was 20% (range 4%-29%). The mean GOS-E score for patients in the 6- to 10-mm group crossed from unfavorable outcome (GOS-E scores 2 and 3) into favorable outcome (GOS-E scores 4-8) at 90 days, and the mean GOS-E of patients in the > 10-mm group nearly reached the threshold of favorable outcome by 180 days postinjury. CONCLUSIONS In this secondary analysis of the Phase 3 COBRIT trial, TBI patients with less than 10 mm of midline shift on admission head CT had significantly improved functional outcomes through 180 days after injury compared with those with greater than 10 mm of midline shift. Of note, nearly 50% of patients with > 10 mm of midline shift achieved a favorable outcome (GOS-E score 4-8) by 6 months postinjury.
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Affiliation(s)
- Ross C Puffer
- 1Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - John K Yue
- 2Department of Neurosurgery, UPMC, Pittsburgh; and
| | | | | | | | | | - Ava Puccio
- 2Department of Neurosurgery, UPMC, Pittsburgh; and
| | - Ramon Diaz-Arrastia
- 3Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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