Patient age and outcome following severe traumatic brain injury: an analysis of 5600 patients

[Polytrauma and concomitant traumatic brain injury : The role of the trauma surgeon]

BACKGROUND

Concomitant traumatic brain injury (TBI) increases mortality and reduces quality of life of polytrauma patients. These facts demand effective treatment strategies while the growing specialization of medicine is questioning the role of the trauma surgeon in the management of these patients.

OBJECTIVES

Which factors influence outcome of polytrauma with concomitant TBI? Who should be responsible for the management of these patients and what is the limit of management?

MATERIALS AND METHODS

A literature search using Medline via PubMed was performed with Medical Subject Headings and text word search.

RESULTS

The crucial factors for outcome are absence of hypotension, adherence to pre- and in-hospital standards like fast transportation to appropriate centers, priority-based diagnostic and therapeutic strategies and strict adherence to principles of damage control surgery. Patients with polytrauma and TBI are treated by different specialties around the world based on the trauma system, geographic circumstances and resources. Investigations of operative and conservative management by different medical specialties showed comparable outcomes.

CONCLUSIONS

In an age of standardization and a high degree of specialization in the field of medicine, the trauma surgeon still seems to be able to ensure an optimal treatment of polytrauma and concomitant TBI by focusing on priority-based diagnostic and therapeutic strategies and adhering to principles of damage control surgery.

The impact of Glasgow Coma Scale-age prognosis score on geriatric traumatic brain injury outcomes

BACKGROUND

As the population ages, increasing number of geriatric patients sustain traumatic brain injury (TBI). Communication of accurate prognostic information is crucial for making informed decisions on behalf of such patients. Therefore, the aim of our study was to develop a simple and clinically applicable tool that accurately predicts the prognosis in geriatric TBI patients.

METHODS

We performed a 1-y (2011) retrospective analysis of isolated geriatric TBI patients (age ≥65 y, head abbreviated injury score [AIS] ≥ 3, and other body AIS < 3) in the National Trauma Data Bank. We calculated a Glasgow Coma Scale (GCS)-age prognosis (GAP) score (age/GCS score) for all patients. Outcome measures were in-hospital adverse outcomes (mortality and Rehab/skilled nursing facility discharge disposition). Regression analysis and receiver operator characteristic curve analysis were performed to determine the discriminatory power of GAP score.

RESULTS

A total of 8750 geriatric patients with TBI were included. Mean age was 77.8 ± 7.1 y, the median (interquartile range) GCS was 15 (13-15), and the median (interquartile range) head AIS was 4 (3-4). The overall in-hospital mortality rate was 12.7%, and 34.2% of the patients were discharged home. As the GAP score increased, the mortality rate increased and discharge to-home decreased. Receiver operator characteristic curve analysis revealed excellent discriminatory power for mortality (area under the curve: 0.826). Above a GAP score of 12, the mortality rate was >50% and more than 45% of the patients were discharged to Rehab/skilled nursing facility.

CONCLUSIONS

For geriatric patients with TBI, a simple GAP score reliably predicts outcomes. A score above 12 results in a drastic increase in mortality and an adverse discharge disposition. This simple tool may help clinicians provide accurate prognostic information to patients' families.

Severe trauma in the geriatric population

Geriatric trauma constitutes an increasingly recognized problem. Aging results in a progressive decline in cellular function which leads to a loose of their capacity to respond to injury. Some medications commonly used in this population can mask or blunt the response to injury. Falls constitute the most common cause of trauma and the leading cause of trauma-related deaths in this population. Falls are complicated by the widespread use of antiplatelets and anticoagulants, especially in patients with brain injury. Under-triage is common in this population. Evaluation of frailty could be helpful to solve this issue. Appropriate triaging and early aggressive management with correction of coagulopathy can improve outcome. Limitation of care and palliative measures must be considered in cases with a clear likelihood of poor prognosis.

Advancing age and ischemia elevate the electric threshold to elicit spreading depolarization in the cerebral cortex of young adult rats

Spreading depolarizations of long cumulative duration have been implicated in lesion development and progression in patients with stroke and traumatic brain injury. Spreading depolarizations evolve less likely in the aged brain, but it remains to be determined at what age the susceptibility to spreading depolarizations starts to decline, especially in ischemia. Spreading depolarizations were triggered by epidural electric stimulation prior and after ischemia induction in the cortex of 7-30 weeks old anesthetized rats ( n = 38). Cerebral ischemia was achieved by occlusion of both common carotid arteries. Spreading depolarization occurrence was confirmed by the acquisition of DC potential and electrocorticogram. Cerebral blood flow variations were recorded by laser-Doppler flowmetry. Dendritic spine density in the cortex was determined in Golgi-COX stained sections. Spreading depolarization initiation required increasingly greater electric charge with older age, a potential outcome of consolidation of cortical connections, indicated by altered dendritic spine distribution. The threshold of spreading depolarization elicitation increased with ischemia in all age groups, which may be caused by tissue acidosis and increased K+ conductance, among other factors. In conclusion, the brain appears to be the most susceptible to spreading depolarizations at adolescent age; therefore, spreading depolarizations may occur in young patients of ischemic or traumatic brain injury at the highest probability.

A prospective outcome study observing patients with severe traumatic brain injury over 10-15 years

BACKGROUND

Severe traumatic brain injury (sTBI) can be divided into primary and secondary injuries. Intensive care protocols focus on preventing secondary injuries. This prospective cohort study was initiated to investigate outcome, including mortality, in patients treated according to the Lund Concept after a sTBI covering 10-15 years post-trauma.

METHODS

Patients were included during 2000-2004 when admitted to the neurointensive care unit, Sahlgrenska University Hospital. Inclusion criteria were: Glasgow coma scale score of ≤8, need for artificial ventilation and intracranial monitoring. Glasgow Outcome Scale (GOS) was used to evaluate outcome both at 1-year and 10-15 years post-trauma.

RESULTS

Ninety-five patients, (27 female and 68 male), were initially included. Both improvement and deterioration were noted between 1- and 10-15 years post-injury. Mortality rate (34/95) was higher in the studied population vs. a matched Swedish population, (Standard mortality rate (SMR) 9.5; P < 0.0001). When dividing the cohort into Good (GOS 4-5) and Poor (GOS 2-3) outcome at 1-year, only patients with Poor outcome had a higher mortality rate than the matched population (SMR 7.3; P < 0.0001). Further, good outcome (high GOS) at 1-year was associated with high GOS 10-15 years post-trauma (P < 0.0001). Finally, a majority of patients demonstrated symptoms of mental fatigue.

CONCLUSION

This indicates that patients with severe traumatic brain injury with Good outcome at 1-year have similar survival probability as a matched Swedish population and that high Glasgow outcome scale at 1-year is related to good long-term outcome. Our results further emphasise the advantage of the Lund concept.

Predictors for Depressive Mood in Geriatric Patients After Traumatic Brain Injury: A Retrospective Cross-Sectional Study

Objective

To identify predictors for depressive mood in geriatric patients after traumatic brain injury (TBI).

Methods

A retrospective review of patients' medical charts was performed in TBI patients who were older than 60 years and referred to the Department of Rehabilitation Medicine at Severance Hospital in 2002–2016. The patients were classified into two groups based on the Geriatric Depression Scale (GDS): non-depressive group (0≤GDS≤16) and depressive group (17≤GDS≤30). Data was collected on demographic, socioeconomic, comorbidities, and trauma-related factors, as well as the pathophysiology of TBI, localization of lesion, post-traumatic complications, functional level, and cognitive and linguistic function. Significant variables from univariate analysis were analyzed using logistic regression.

Results

Forty-two patients were included, of whom 64.3% displayed a depressive mood. Patients in the depressive group had higher comorbidity scores (p=0.03), lower Functional Independence Measure (FIM) totals (p=0.03) and FIM motor (p=0.03) scores, higher modified Rankin Scale scores (p=0.04), and frequently had a bilateral or left side brain lesion (p=0.002). Higher comorbidity scores (odds ratio [OR], 1.764; 95% confidence interval [CI], 1.047–2.971), bilateral lesions (OR, 13.078; 95% CI, 1.786–95.780), and left side lesions (OR, 46.074; 95% CI, 3.175–668.502) were independently associated with a depressive mood in the multiple logistic regression analysis.

Conclusion

The risk of depressive mood in geriatric patients after TBI is associated with comorbidity, functional limitation, and the horizontal distribution of brain lesions. The most significant determining factors were comorbidity and the horizontal distribution of brain lesions. Early detection of risk factors is important to prevent and manage depressive mood in geriatric patients after TBI.

Relationship between age and outcomes of comatose cardiac arrest survivors in a setting without withdrawal of life support

AIM OF THE STUDY

Previous studies on the relationship between age and outcomes after cardiac arrest were performed in settings where the majority of patients died after the withdrawal of life support (WLS). We examined the association between age and outcomes of comatose cardiac arrest survivors in a setting where WLS was not performed.

METHODS

This single-centre retrospective observational study included adult comatose cardiac arrest survivors treated with targeted temperature management. In Korea, WLS is not permitted unless the patient is pronounced brain-dead. The primary outcome was poor neurologic outcome at hospital discharge, defined as Cerebral Performance Categories scores of 3-5. The secondary outcomes were in-hospital and six-month mortalities.

RESULTS

A total of 534 patients were analysed. In multivariate analysis, age was not associated with in-hospital mortality (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.99-1.02), but it was independently associated with neurologic outcome at hospital discharge (OR, 1.03; 95% CI, 1.02-1.05) and six-month mortality (OR, 1.05; 95% CI, 1.03-1.07). When age was categorised into 10-year intervals, age groups less than 61-70 years had significantly lower OR for poor neurologic outcome compared with the reference group (61-70 years), while the OR for poor neurologic outcome in age groups greater than 70 years did not differ from that in the reference group.

CONCLUSION

In a setting where WLS is not performed, we found that age was not associated with in-hospital mortality but was independently associated with neurologic outcome at hospital discharge and six-month mortality.

Predicting Mortality and Independence at Discharge in the Aging Traumatic Brain Injury Population Using Data Available at Admission

BACKGROUND

Aging worsens outcome in traumatic brain injury (TBI), but available studies may not provide accurate outcomes predictions due to confounding associated injuries. Our goal was to develop a predictive tool using variables available at admission to predict outcomes related to severity of brain injury in aging patients.

STUDY DESIGN

Characteristics and outcomes of blunt trauma patients, aged 50 or older, with isolated TBI, in the National Trauma Data Bank (NTDB), were evaluated. Equations predicting survival and independence at discharge (IDC) were developed and validated using patients from our trauma registry, comparing predicted with actual outcomes.

RESULTS

Logistic regression for survival and IDC was performed in 57,588 patients using age, sex, Glasgow Coma Scale score (GCS), and Revised Trauma Score (RTS). All variables were independent predictors of outcome. Two models were developed using these data. The first included age, sex, and GCS. The second substituted RTS for GCS. C statistics from the models for survival and IDC were 0.90 and 0.82 in the GCS model. In the RTS model, C statistics were 0.80 and 0.67. The use of GCS provided better discrimination and was chosen for further examination. Using a predictive equation derived from the logistic regression model, outcome probabilities were calculated for 894 similar patients from our trauma registry (January 2012 to March 2016). The survival and IDC models both showed excellent discrimination (p < 0.0001). Survival and IDC generally decreased by decade: age 50 to 59 (80% IDC, 6.5% mortality), 60 to 69 (82% IDC, 7.0% mortality), 70 to 79 (76% IDC, 8.9% mortality), and 80 to 89 (67% IDC, 13.4% mortality).

CONCLUSIONS

These models can assist in predicting the probability of survival and IDC for aging patients with TBI. This provides important data for loved ones of these patients when addressing goals of care.

Disordered APP metabolism and neurovasculature in trauma and aging: Combined risks for chronic neurodegenerative disorders

Traumatic brain injury (TBI), advanced age, and cerebral vascular disease are factors conferring increased risk for late onset Alzheimer's disease (AD). These conditions are also related pathologically through multiple interacting mechanisms. The hallmark pathology of AD consists of pathological aggregates of amyloid-β (Aβ) peptides and tau proteins. These molecules are also involved in neuropathology of several other chronic neurodegenerative diseases, and are under intense investigation in the aftermath of TBI as potential contributors to the risk for developing AD and chronic traumatic encephalopathy (CTE). The pathology of TBI is complex and dependent on injury severity, age-at-injury, and length of time between injury and neuropathological evaluation. In addition, the mechanisms influencing pathology and recovery after TBI likely involve genetic/epigenetic factors as well as additional disorders or comorbid states related to age and central and peripheral vascular health. In this regard, dysfunction of the aging neurovascular system could be an important link between TBI and chronic neurodegenerative diseases, either as a precipitating event or related to accumulation of AD-like pathology which is amplified in the context of aging. Thus with advanced age and vascular dysfunction, TBI can trigger self-propagating cycles of neuronal injury, pathological protein aggregation, and synaptic loss resulting in chronic neurodegenerative disease. In this review we discuss evidence supporting TBI and aging as dual, interacting risk factors for AD, and the role of Aβ and cerebral vascular dysfunction in this relationship. Evidence is discussed that Aβ is involved in cyto- and synapto-toxicity after severe TBI, and that its chronic effects are potentiated by aging and impaired cerebral vascular function. From a therapeutic perspective, we emphasize that in the fields of TBI- and aging-related neurodegeneration protective strategies should include preservation of neurovascular function.

Predictors of improved functional outcome following inpatient rehabilitation for patients with traumatic brain injury

OBJECTIVE

To determine factors associated with response to inpatient rehabilitation treatment among TBI patients.

SETTING

Inpatient rehabilitation service at a Level I trauma center.

PARTICIPANTS

Moderate-severe TBI patients ages ≥ 18years old admitted between January 1, 2002 and December 31, 2012.

MAIN MEASURES

Response to inpatient rehabilitation, measured by the Functional Independence Measure (FIM) score.

DESIGN

Retrospective cohort study.

RESULTS

Of 1,984 patients treated for TBI, 184 (10.8%) underwent inpatient rehabilitation. The largest proportion of patients improved in mobility (98.9%), followed by self-care (93.7%), communication/social cognition (84.0%), and sphincter control (65.7%). Of these, 99 (53.8%) improved by 2 or more levels of functional independence and were considered rehabilitation responders. Responders were younger (53.1 years vs. 63.8, p < 0.01), had longer average rehabilitation stays (15.4 days vs. 12.2, p < 0.01), and were less likely to have an admission SBP <100 mmHg (7.1% vs. 17.1%, p = 0.01). On multivariate analysis, normotension at admission (AOR 0.06, p = 0.01) and longer rehabilitation LOS (AOR 1.11, p < 0.01) were associated with a response to inpatient rehabilitation.

CONCLUSION

Of the TBI patients who qualified for same-center inpatient rehabilitation, approximately half responded to treatment. Longer rehabilitation time and normotension at admission predicted response to rehabilitation. Further efforts are necessary to identify and optimize TBI patients for inpatient rehabilitation.

Subdural hematoma as a major determinant of short-term outcomes in traumatic brain injury

OBJECTIVE Early radiographic findings in patients with traumatic brain injury (TBI) have been studied in hopes of better predicting injury severity and outcome. However, prior attempts have generally not considered the various types of intracranial hemorrhage in isolation and have typically not excluded patients with potentially confounding extracranial injuries. Therefore, the authors examined the associations of various radiographic findings with short-term outcome to assess the potential utility of these findings in future prognostic models. METHODS The authors retrospectively identified 1716 patients who had experienced TBI without major extracranial injuries, and categorized them into the following TBI subtypes: subdural hematoma (SDH), traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage (which included intraventricular hemorrhage), and epidural hematoma. They specifically considered isolated forms of hemorrhage, in which only 1 subtype was present. RESULTS In general, the presence of an isolated SDH was more likely to result in worse outcomes than the presence of other isolated forms of traumatic intracranial hemorrhage. Discharge to home was less likely and perihospital mortality rates were generally higher in patients with SDH. These findings were not simply related to age and were not fully captured by the admission Glasgow Coma Scale (GCS) score. The presence of SDH had a much higher sensitivity for poor outcome than the presence of other TBI subtypes, and was more sensitive for these poor outcomes than having a low GCS score (3-8). CONCLUSIONS In these ways, SDH was the most important finding associated with poor outcome, and the authors show that consideration of SDH, specifically, can augment age and GCS score in classification and prognostic models for TBI.

Neurologic Emergencies in the Elderly

Neurologic diseases are a major cause of death and disability in elderly patients. Due to the physiologic changes and increased comorbidities that occur as people age, neurologic diseases are more common in geriatric patients and a major cause of death and disability in this population. This article discusses the elderly patient presenting to the emergency department with acute ischemic stroke, transient ischemic attack, intracerebral hemorrhage, subarachnoid hemorrhage, chronic subdural hematoma, traumatic brain injury, seizures, and central nervous system infections. This article reviews the subtle presentations, difficult workups, and complicated treatment decisions as they pertain to our older patients."

Traumatic brain injury and palliative care: a retrospective analysis of 49 patients receiving palliative care during 2013-2016 in Turkey

Traumatic brain injury (TBI), which is seen more in young adults, affects both patients and their families. The need for palliative care in TBI and the limits of the care requirement are not clear. The aim of this study was to investigate the length of stay in the palliative care center (PCC), Turkey, the status of patients at discharge, and the need for palliative care in patients with TBI. The medical records of 49 patients with TBI receiving palliative care in PCC during 2013–2016 were retrospectively collected, including age and gender of patients, the length of stay in PCC, the cause of TBI, diagnosis, Glasgow Coma Scale score, Glasgow Outcome Scale score, Karnofsky Performance Status score, mobilization status, nutrition route (oral, percutaneous endoscopic gastrostomy), pressure ulcers, and discharge status. These patients were aged 45.4 ± 20.2 years. The median length of stay in the PCC was 34.0 days. These included TBI patients had a Glasgow Coma Scale score ≤ 8, were not mobilized, received tracheostomy and percutaneous endoscopic gastrostomy nutrition, and had pressure ulcers. No difference was found between those who were discharged to their home or other places (rehabilitation centre, intensive care unit and death) in respect of mobilization, percutaneous endoscopic gastrostomy, tracheostomy and pressure ulcers. TBI patients who were followed up in PCC were determined to be relatively young patients (45.4 ± 20.2 years) with mobilization and nutrition problems and pressure ulcer formation. As TBI patients have complex health conditions that require palliative care from the time of admittance to intensive care unit, provision of palliative care services should be integrated with clinical applications.

Aging with a traumatic brain injury: Could behavioral morbidities and endocrine symptoms be influenced by microglial priming?

A myriad of factors influence the developmental and aging process and impact health and life span. Mounting evidence indicates that brain injury, even moderate injury, can lead to lifetime of physical and mental health symptoms. Therefore, the purpose of this mini-review is to discuss how recovery from traumatic brain injury (TBI) depends on age-at-injury and how aging with a TBI affects long-term recovery. TBI initiates pathophysiological processes that dismantle circuits in the brain. In response, reparative and restorative processes reorganize circuits to overcome the injury-induced damage. The extent of circuit dismantling and subsequent reorganization depends as much on the initial injury parameters as other contributing factors, such as genetics and age. Age-at-injury influences the way the brain is able to repair itself, as a result of developmental status, extent of cellular senescence, and injury-induced inflammation. Moreover, endocrine dysfunction can occur with TBI. Depending on the age of the individual at the time of injury, endocrine dysfunction may disrupt growth, puberty, influence social behaviors, and possibly alter the inflammatory response. In turn, activation of microglia, the brain's immune cells, after injury may continue to fuel endocrine dysfunction. With age, the immune system develops and microglia become primed to subsequent challenges. Sustained inflammation and microglial activation can continue for weeks to months post-injury. This prolonged inflammation can influence developmental processes, behavioral performance and age-related decline. Overall, brain injury may influence the aging process and expedite glial and neuronal alterations that impact mental health.

Age and Diet Affect Genetically Separable Secondary Injuries that Cause Acute Mortality Following Traumatic Brain Injury in Drosophila

Outcomes of traumatic brain injury (TBI) vary because of differences in primary and secondary injuries. Primary injuries occur at the time of a traumatic event, whereas secondary injuries occur later as a result of cellular and molecular events activated in the brain and other tissues by primary injuries. We used a Drosophila melanogaster TBI model to investigate secondary injuries that cause acute mortality. By analyzing mortality percentage within 24 hr of primary injuries, we previously found that age at the time of primary injuries and diet afterward affect the severity of secondary injuries. Here, we show that secondary injuries peaked in activity 1–8 hr after primary injuries. Additionally, we demonstrate that age and diet activated distinct secondary injuries in a genotype-specific manner, and that concurrent activation of age- and diet-regulated secondary injuries synergistically increased mortality. To identify genes involved in secondary injuries that cause mortality, we compared genome-wide mRNA expression profiles of uninjured and injured flies under age and diet conditions that had different mortalities. During the peak period of secondary injuries, innate immune response genes were the predominant class of genes that changed expression. Furthermore, age and diet affected the magnitude of the change in expression of some innate immune response genes, suggesting roles for these genes in inhibiting secondary injuries that cause mortality. Our results indicate that the complexity of TBI outcomes is due in part to distinct, genetically controlled, age- and diet-regulated mechanisms that promote secondary injuries and that involve a subset of innate immune response genes.

The application of adult traumatic brain injury models in a pediatric cohort

OBJECTIVE There is increasing interest in the use of predictive models of outcome in adult head injury. Two international models have been identified to be reliable modalities for predicting outcome: the Corticosteroid Randomisation After Significant Head Injury (CRASH) model, and the International Mission on Prognosis and Analysis of randomized Controlled Trials in TBI (IMPACT) model. However, these models are designed only to identify outcomes in adult populations. METHODS A retrospective analysis was performed on pediatric patients with severe traumatic brain injury (TBI) admitted to the pediatric intensive care unit (PICU) of Addenbrooke's Hospital between January 2009 and December 2013. The individual risk of 14-day mortality was calculated using the CRASH-Basic and -CT models, and the risk of 6-month mortality calculated using the IMPACT-Core and -Extended (including CT findings) models. Model accuracy was determined by standardized mortality ratio (SMtR; observed/expected deaths), discrimination was evaluated as the area under the receiver operating curve (AUROC), and calibration assessed using the Hosmer-Lemeshow χ² test. RESULTS Ninety-four patients with an average age of 7.3 years were admitted to the PICU with a TBI. The mortality rate was 12.7% at 14 days and at 6 months. For the CRASH-Basic model, the SMtR was 1.42 and both calibration (χ² = 6.1, p = 0.64) and discrimination (AUROC = 0.92) were good. For the IMPACT-Core model, the SMtR was 1.03 and the model was also well calibrated (χ² = 8.99, p = 0.34) and had good discrimination (AUROC = 0.85). Poor outcome was observed in 17% of the cohort and identified with the CRASH-Basic and IMPACT-Core models to varying degrees: standardized morbidity ratio = 0.89 vs 0.67, respectively; calibration = 6.5 (χ²) and 0.59 (p value) versus 8.52 (χ²) and 0.38 (p value), respectively; and discrimination (AUROC) = 0.92 versus 0.83, respectively. CONCLUSIONS Adult head injury models may be applied with sufficient accuracy to identify predictors of morbidity and mortality in pediatric TBI.

Differences in cognitive profiles between traumatic brain injury and stroke: A comparison of the Montreal Cognitive Assessment and Mini-Mental State Examination

PURPOSE

To investigate the profiles of cognitive impairment through Montreal Cognitive Assessment (MoCA) and Mini-Mental State Examination (MMSE) in patients with chronic traumatic brain injury (TBI) or stroke and to evaluate the sensitivity of the two scales in patients with TBI.

METHODS

In this cohort study, a total of 230 patients were evaluated, including TBI group (n = 103) and stroke group (n = 127). The cognitive functions of two groups were evaluated by designated specialists using MoCA (Beijing version) and MMSE (Chinese version).

RESULTS

Comparedwith the patientswith stroke, the patientswith TBI received significantly lower score in orientation subtest and recall subtest in both tests.MoCA abnormal rates in the TBI group and stroke group were 94.17% and 86.61% respectively,whileMMSE abnormal rateswere 69.90% and 57.48%, respectively. In the TBI group, 87.10% patientswith normalMMSE score had abnormalMoCA score and in the stroke group, about 70.37% patients with normal MMSE score had abnormal MoCA score. The diagnostic consistency of two scales in the TBI group and the stroke group were 72% and 69%, respectively.

CONCLUSION

In our rehabilitation center, patients with TBI may have more extensive and severe cognitive impairments than patients with stroke, prominently in orientation and recall domain. In screening post- TBI cognitive impairment, MoCA tends to be more sensitive than MMSE.

Pumping the Brakes: Neurotrophic Factors for the Prevention of Cognitive Impairment and Dementia after Traumatic Brain Injury

Traumatic brain injury (TBI) is the leading cause of disability and death worldwide, affecting as many as 54,000,000-60,000,000 people annually. TBI is associated with significant impairments in brain function, impacting cognitive, emotional, behavioral, and physical functioning. Although much previous research has focused on the impairment immediately following injury, TBI may have much longer-lasting consequences, including neuropsychiatric disorders and cognitive impairment. TBI, even mild brain injury, has also been recognized as a significant risk factor for the later development of dementia and Alzheimer's disease. Although the link between TBI and dementia is currently unknown, several proposed mechanisms have been put forward, including alterations in glucose metabolism, excitotoxicity, calcium influx, mitochondrial dysfunction, oxidative stress, and neuroinflammation. A treatment for the devastating long-term consequences of TBI is desperately needed. Unfortunately, however, no such treatment is currently available, making this a major area of unmet medical need. Increasing the level of neurotrophic factor expression in key brain areas may be one potential therapeutic strategy. Of the neurotrophic factors, granulocyte-colony stimulating factor (G-CSF) may be particularly effective for preventing the emergence of long-term complications of TBI, including dementia, because of its ability to reduce apoptosis, stimulate neurogenesis, and increase neuroplasticity.

Functional outcomes of motor vehicle crash head injuries in pediatric and adult occupants

OBJECTIVE

The objective of the study was to develop a disability-based metric for motor vehicle crash (MVC) injuries, with a focus on head injuries, and compare the functional outcomes between the pediatric and adult populations.

METHODS

Disability risk (DR) was quantified using Functional Independence Measure (FIM) scores within the National Trauma Data Bank-Research Data System (NTDB-RDS) for the top 95% most frequently occurring Abbreviated Injury Scale (AIS) 3, 4, and 5 head injuries in NASS-CDS 2000-2011. Pediatric (ages 7-18), adult (19-45), middle-aged (46-65), and older adult (66+) patients with an FIM score available who were alive at discharge and had an AIS 3, 4, or 5 injury were included in the study. The NTDB-RDS contains a truncated form of the FIM instrument, including 3 items (self-feed, locomotion, and verbal expression), each graded on a scale of 1 (full functional dependence) to 4 (full functional independence). Patients within each age group were classified as disabled or not disabled based on the FIM scale. The DR was calculated for each age group by dividing the number of patients who sustained a specific injury and were disabled by the number of patients who sustained the specific injury. To account for the impact of more severe associated coinjuries, a maximum AIS (MAIS) adjusted DR (DRMAIS) was also calculated for each injury. DR and DRMAIS ranged from 0 (0% disability risk) to 1 (100% disability risk).

RESULTS

An analysis of the most frequent FIM components associated with disabling MVC head injuries revealed that disability across all 3 items (self-feed, locomotion, and expression) was the most frequent for pediatric and adult patients. Only locomotion was the most frequent for middle-aged and older adults. The mean DRMAIS for MVC head injuries was 35% for pediatric patients, 36% for adults, 38% for middle-aged adults, and 44% for older adults. Further analysis was conducted by grouping the head injuries into 8 groups based on the structure of injury and injury type. The pediatric population possessed higher DRMAIS values for brain stem injuries as well as loss of consciousness injuries. Older adults possessed higher DRMAIS values for contusion/hemorrhage injuries, epidural hemorrhage, intracerebral hemorrhage, skull fracture, and subdural/subarachnoid hemorrhage.

CONCLUSION

At-risk populations such as pediatric and older adult patients possessed higher DRMAIS values for different head injuries. Disability in pediatric patients is critical due to loss of quality life years. Disability risk can supplement severity metrics to improve the ability of such metrics to discriminate the severity of different injuries that do not lead to death. Understanding of age-related differences in injury outcomes when compared to adults could inform future age-specific modifications to the AIS.

Effectiveness of a Very Early Stepping Verticalization Protocol in Severe Acquired Brain Injured Patients: A Randomized Pilot Study in ICU

BACKGROUND AND OBJECTIVE

Verticalization was reported to improve the level of arousal and awareness in patients with severe acquired brain injury (ABI) and to be safe in ICU. We evaluated the effectiveness of a very early stepping verticalization protocol on their functional and neurological outcome.

METHODS

Consecutive patients with Vegetative State or Minimally Conscious State were enrolled in ICU on the third day after an ABI. They were randomized to undergo conventional physiotherapy alone or associated to fifteen 30-minute sessions of verticalization, using a tilt table with robotic stepping device. Once stabilized, patients were transferred to our Neurorehabilitation unit for an individualized treatment. Outcome measures (Glasgow Coma Scale, Coma Recovery Scale revised -CRSr-, Disability Rating Scale-DRS- and Levels of Cognitive Functioning) were assessed on the third day from the injury (T0), at ICU discharge (T1) and at Rehab discharge (T2). Between- and within-group comparisons were performed by the Mann-Whitney U test and Wilcoxon signed-rank test, respectively.

RESULTS

Of the 40 patients enrolled, 31 completed the study without adverse events (15 in the verticalization group and 16 in the conventional physiotherapy). Early verticalization started 12.4±7.3 (mean±SD) days after ABI. The length of stay in ICU was longer for the verticalization group (38.8 ± 15.7 vs 25.1 ± 11.2 days, p = 0.01), while the total length of stay (ICU+Neurorehabilitation) was not significantly different (153.2 ± 59.6 vs 134.0 ± 61.0 days, p = 0.41). All outcome measures significantly improved in both groups after the overall period (T2 vs T0, p<0.001 all), as well as after ICU stay (T1 vs T0, p<0.004 all) and after Neurorehabilitation (T2 vs T1, p<0.004 all). The improvement was significantly better in the experimental group for CRSr (T2-T0 p = 0.033, T1-T0 p = 0.006) and (borderline) for DRS (T2-T0 p = 0.040, T1-T0 p = 0.058).

CONCLUSIONS

A stepping verticalization protocol, started since the acute stages, improves the short-term and long-term functional and neurological outcome of ABI patients.

TRIAL REGISTRATION

clinicaltrials.gov NCT02828371.

The role of cardiac troponin I in prognostication of patients with isolated severe traumatic brain injury

BACKGROUND

Cardiac dysfunction is frequently observed after severe traumatic brain injury (sTBI); however, its significance is poorly understood. Our study sought to elucidate the association of cardiac troponin I (cTnI) elevation with all-cause in-hospital mortality following isolated sTBI (brain Abbreviated Injury Scale score ≥3 and admission Glasgow Coma Scale score ≤8, no Abbreviated Injury Scale score ≥3 to any other bodily regions).

METHODS

We retrospectively reviewed all adult patients (aged ≥18 years) with isolated sTBI admitted to a Level I trauma center between June 2007 and January 2014. Patients must have cTnI values within 24 hours of admission. Mortality risks were examined by Cox proportional hazard model.

RESULTS

Of 580 patients identified, 30.9% had detectable cTnI in 24 hours of admission. The median survival time was 4.19 days (interquartile range, 1.27-11.69). When adjusted for potential confounders, patients in the highest cTnI category (≥0.21 ng/mL) had a significantly higher risk of in-hospital mortality (hazard ratio, 1.39; 95% confidence interval, 1.04-1.88) compared with patients with undetectable cTnI. Mortality risk increased with higher troponin levels (p < 0.0001). This association was more pronounced in patients aged 65 years or younger (hazard ratio, 2.28; 95% confidence interval, 1.53-3.40; p < 0.0001) while, interestingly, insignificant in those older than 65 years (p = 0.0826).

CONCLUSION

Among patients with sTBI, cTnI elevation is associated with all-cause in-hospital mortality via a nonlinear positive trend. Age modified the effect of cTnI on mortality.

LEVEL OF EVIDENCE

Prognostic and epidemiologic study, level III.

Older Age Results in Differential Gene Expression after Mild Traumatic Brain Injury and Is Linked to Imaging Differences at Acute Follow-up

Older age consistently relates to a lesser ability to fully recover from a traumatic brain injury (TBI); however, there is limited data to explicate the nature of age-related risks. This study was undertaken to determine the relationship of age on gene-activity following a TBI, and how this biomarker relates to changes in neuroimaging findings. A young group (between the ages of 19 and 35 years), and an old group (between the ages of 60 and 89 years) were compared on global gene-activity within 48 h following a TBI, and then at follow-up within 1-week. At each time-point, gene expression profiles, and imaging findings from both magnetic resonance imaging (MRI) and computed tomography were obtained and compared. The young group was found to have greater gene expression of inflammatory regulatory genes at 48 h and 1-week in genes such as basic leucine zipper transcription factor 2 (BACH2), leucine-rich repeat neuronal 3 (LRRN3), and lymphoid enhancer-binding factor 1 (LEF1) compared to the old group. In the old group, there was increased activity in genes within S100 family, including calcium binding protein P (S100P) and S100 calcium binding protein A8 (S100A8), which previous studies have linked to poor recovery from TBI. The old group also had reduced activity of the noggin (NOG) gene, which is a member of the transforming growth factor-β superfamily and is linked to neurorecovery and neuroregeneration compared to the young group. We link these gene expression findings that were validated to neuroimaging, reporting that in the old group with a MRI finding of TBI-related damage, there was a lesser likelihood to then have a negative MRI finding at follow-up compared to the young group. Together, these data indicate that age impacts gene activity following a TBI, and suggest that this differential activity related to immune regulation and neurorecovery contributes to a lesser likelihood of neuronal recovery in older patients as indicated through neuroimaging.

Intraventricular intracranial pressure monitoring improves the outcome of older adults with severe traumatic brain injury: an observational, prospective study

BACKGROUND

Intracranial pressure (ICP) monitoring is widely used in the management of patients with severe traumatic brain injury (TBI). However, there is limited evidence about the efficacy of ICP monitoring in older subjects (aged ≥65 years). This study evaluated the effect of intraventricular ICP monitoring on the outcome of older adults suffering from a severe TBI.

METHODS

This prospective, observational study included 166 older TBI patients (aged ≥65 years) with Glasgow Coma scale (GCS) scores lower than 9 at admission. The study cohort was divided into two groups, intraventricular ICP monitoring and non-ICP monitoring. The primary outcome was in-hospital mortality. The secondary outcomes included the Glasgow Outcome Scale (GOS) score 6 months after injury, the ICU and total hospital lengths of stay, and mechanical ventilation days.

RESULTS

There were 80 patients in the intraventricular ICP monitoring group and 86 patients in non-ICP monitoring group. There was no statistical difference between groups in demographics and severity of head injury. Patients treated with intraventricular ICP monitoring had lower in-hospital mortality (33.8 % vs 51.2 %, P < 0.05), a higher 6-month GOS score (3.0 ± 1.4 vs 2.5 ± 1.2 P < 0.05), and a lower dosage (514 ± 246 g vs 840 ± 323 g, P < 0.0001) and shorter duration (7.2 ± 3.6 days vs 8.4 ± 4.3 days, P < 0.01) of mannitol use. However, the ICU length of stay (14.3 ± 6.4 days vs 11.6 ± 5.8 days, P < 0.01) and mechanical ventilation days (6.7 ± 3.5 days vs 5.6 ± 2.4 days, P < 0.05) were longer in the ICP monitoring group. The total length of hospital stay did not differ between the two groups (28.5 ± 12.1 days vs 26.1 ± 13.5 days, P = 0.23).

CONCLUSIONS

Intraventricular ICP monitoring may have beneficial effects on the decreased in-hospital mortality and improved 6-month outcome of older patients with severe TBI. However, given that this was an observational study conducted in a single institution, further well-designed randomized control trials are needed to evaluate the effect of intraventricular ICP monitoring on the outcome of older severe TBI patients.

Trends in Hospitalization Associated with TBI in an Urban Level 1 Trauma Centre

OBJECTIVE

Traumatic brain injury (TBI) is the single largest cause of death and disability following injury worldwide. The aim of this study was to determine the demographic, clinical, medical and accident related trends for patients with TBI hospitalized in an urban level 1 Trauma Centre.

METHODS

Data were retrospectively collected on individuals (n = 5,642) who were admitted to the Traumatic Brain Injury Program of the McGill University Health Centre - Montreal General Hospital from 2000 to 2011.

RESULTS

Regression analysis showed a significant upward trend in the yearly number of cases as well as an upward trending by year in the proportion of TBI cases aged 70-years-old or more. The Injury Severity Scale scores were positively associated with year indicating a slight increase in injury severity over the years and there was an increase in patient psychological, social and medical premorbid complexity. In addition, the Extended Glasgow Outcome Scale score tended to become more severe over the years. There was a slight decrease in the proportion of discharges home and in the proportion of deaths.

CONCLUSIONS

These results will help to understand the impact of TBI in an urban Canadian level 1 Trauma Centre. This information should be used to develop public prevention strategies and to educate the community about the risk of TBI especially the risk of falls in the ageing population. These findings can also provide information to help health policy makers plan for future resources.

Variation in PPP3CC Genotype Is Associated with Long-Term Recovery after Severe Brain Injury

After experimental traumatic brain injury (TBI), calcineurin is upregulated; blocking calcineurin is associated with improved outcomes. In humans, variation in the calcineurin A-gamma gene (PPP3CC) has been associated with neuropsychiatric disorders, though any role in TBI recovery remains unknown. This study examines associations between PPP3CC genotype and mortality, as well as gross functional status assessed at admission using the Glasgow Coma Scale (GCS) and at 3, 6, and 12 months after severe TBI using the Glasgow Outcome Score (GOS). The following tagging single nucleotide polymorphisms (tSNPs) in PPP3CC were genotyped: rs2443504, rs2461491, rs2469749, and rs10108011. The rs2443504 AA genotype was univariately associated with GCS (p = 0.022), GOS at 3, 6, and 12 months (p = 0.002, p = 0.034, and p = 0.004, respectively), and mortality (p = 0.007). In multivariate analysis controlling for age, sex, and GCS, the AA genotype of rs2443504 was associated with GOS at 3 (p = 0.02), and 12 months (p = 0.01), with a trend toward significance at 6 months (p = 0.05); the AA genotype also was associated with mortality in the multivariate model (p = 0.04). Further work is warranted to better understand the role of calcineurin, as well as the genes encoding it and their relevance to outcomes after brain injury.

Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury

Background

Data regarding the impact and timing of tracheostomy in patients with isolated traumatic brain injury (TBI) are ambiguous. Our goal was to evaluate the impact of tracheostomy on hospital mortality in patients with moderate or severe isolated TBI.

Materials and Methods

We performed a retrospective cohort analysis of data prospectively collected at 87 Austrian intensive care units (ICUs). All patients continuously admitted between 1998 and 2010 were evaluated for the study. In total, 4,735 patients were admitted to ICUs with isolated TBI. Of these patients, 2,156 had a moderate or severe TBI (1,603 patients were endotracheally intubated only, 553 patients underwent tracheostomy). Epidemiological data (trauma severity, treatment, and outcome) of the two groups were compared.

Results

Patients with moderate or severe isolated TBI undergoing tracheostomy had a similar Glasgow Coma Scale score, median (interquartile range): 6 (3–8) vs 6 (3–8); p = 0.90, and Simplified Acute Physiology Score II, 45 (37–54) vs 45 (35–56); p = 0.86, compared with intubated patients not undergoing tracheostomy. Furthermore, patients undergoing tracheostomy exhibited higher Abbreviated Injury Scale Head scores and had a longer ICU stay for survivors, 30 (22–42) vs 9 (3–17) days; p < 0.0001). In contrast, risk-adjusted mortality was lower in patients undergoing tracheostomy compared with patients who remained intubated, observed-to-expected mortality ratio (95 % confidence interval): 0.62 (0.53–0.72) vs 1.00 (0.95–1.05) respectively.

Conclusions

Despite the greater severity of head injury, patients with isolated TBI who underwent tracheostomy had a lower risk-adjusted mortality than patients who remained intubated. Reasons for this difference in outcome may be multifactorial and require further investigation.

Functional resting-state fMRI connectivity correlates with serum levels of the S100B protein in the acute phase of traumatic brain injury

The S100B protein is an intra-cellular calcium-binding protein that mainly resides in astrocytes in the central nervous system. The serum level of S100B is used as biomarker for the severity of brain damage in traumatic brain injury (TBI) patients. In this study we investigated the relationship between intrinsic resting-state brain connectivity, measured 1-22 days (mean 8 days) after trauma, and serum levels of S100B in a patient cohort with mild-to-severe TBI in need of neuro-intensive care in the acute phase. In line with previous investigations, our results show that the peak level of S100B acquired during the acute phase of TBI was negatively correlated with behavioral measures (Glasgow Outcome Score, GOS) of functional outcome assessed 6 to 12 months post injury. Using a multi-variate pattern analysis-informed seed-based correlation analysis, we show that the strength of resting-state brain connectivity in multiple resting-state networks was negatively correlated with the peak of serum levels of S100B. A negative correspondence between S100B peak levels recorded 12-36 h after trauma and intrinsic connectivity was found for brain regions located in the default mode, fronto-parietal, visual and motor resting-state networks. Our results suggest that resting-state brain connectivity measures acquired during the acute phase of TBI is concordant with results obtained from molecular biomarkers and that it may hold a capacity to predict long-term cognitive outcome in TBI patients.

The effect of concomitant peripheral injury on traumatic brain injury pathobiology and outcome

Background

Traumatic injuries are physical insults to the body that are prevalent worldwide. Many individuals involved in accidents suffer injuries affecting a number of extremities and organs, otherwise known as multitrauma or polytrauma. Traumatic brain injury is one of the most serious forms of the trauma-induced injuries and is a leading cause of death and long-term disability. Despite over dozens of phase III clinical trials, there are currently no specific treatments known to improve traumatic brain injury outcomes. These failures are in part due to our still poor understanding of the heterogeneous and evolving pathophysiology of traumatic brain injury and how factors such as concomitant extracranial injuries can impact these processes.

Main body

Here, we review the available clinical and pre-clinical studies that have investigated the possible impact of concomitant injuries on traumatic brain injury pathobiology and outcomes. We then list the pathophysiological processes that may interact and affect outcomes and discuss promising areas for future research. Taken together, many of the clinical multitrauma/polytrauma studies discussed in this review suggest that concomitant peripheral injuries may increase the risk of mortality and functional deficits following traumatic brain injury, particularly when severe extracranial injuries are combined with mild to moderate brain injury. In addition, recent animal studies have provided strong evidence that concomitant injuries may increase both peripheral and central inflammatory responses and that structural and functional deficits associated with traumatic brain injury may be exacerbated in multiply injured animals.

Conclusions

The findings of this review suggest that concomitant extracranial injuries are capable of modifying the outcomes and pathobiology of traumatic brain injury, in particular neuroinflammation. Though additional studies are needed to further identify the factors and mechanisms involved in central and peripheral injury interactions following multitrauma and polytrauma, concomitant injuries should be recognized and accounted for in future pre-clinical and clinical traumatic brain injury studies.

Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study

OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIS_head) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIS_head score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.

Functional Independence Measure in Iran: A Confirmatory Factor Analysis and Evaluation of Ceiling and Floor Effects in Traumatic Brain Injury Patients

Background:

The functional independence measure (FIM) is one of the most important assessment instruments for motor and cognitive dependence in rehabilitation medicine; however, there is little data about its confirmatory factor analysis (CFA) and ceiling/floor effects from other countries and also in Iranian patients.

Objectives:

The aim of this study was to evaluate a two-factor model (motor and cognitive independence as latent variables) and ceiling/floor effects for FIM in Iranian patients with traumatic brain injuries (TBI).

Patients and Methods:

In this cross-sectional study, 185 subacute TBI patients were selected from emergency and neurosurgery departments of Poursina Hospital (the largest trauma hospital in northern Iran, Rasht) using the consecutive sampling method and were assessed for functional independence.

Results:

The results of this study showed that the floor effect was not observed; however, ceiling effects were observed for the FIM total score and its subscales. The confirmatory factor analysis showed that the chi-square/df ratio was 2.8 for the two-factor structure and the fit indices for this structural model including root mean square error of approximation (RMSEA) = 0.099, normed fit index (NFI) = 0.96, tucker lewis index (TLI) = 0.97, comparative fit index (CFI) = 0.97 were close to standard indices.

Conclusions:

Although ceiling effects should be considered for rehabilitation targets, the two-factor model of FIM (motor and cognitive independence) has an eligible fitness for Iranian patients with TBI.

Promising clinical outcome of elderly with TBI after modern neurointensive care

BACKGROUND

The increasing number of elderly patients with traumatic brain injury (TBI) leads to specific neurointensive care (NIC) challenges. Therefore, elderly subjects with TBI need to be further studied. In this study we evaluated the demographics, management and outcome of elderly TBI patients receiving modern NIC.

METHODS

Patients referred to our NIC unit between 2008 and 2010 were included. Patients were divided in two age groups, elderly (E) ≥65 years and younger (Y) 64-15 years. Parameters studied were the dominant finding on CT scans, neurological motor skills and consciousness, type of monitoring, neurosurgical procedures/treatments and Glasgow Outcome Scale Extended score at 6 months after injury.

RESULTS

Sixty-two E (22 %) and 222 Y (78 %) patients were included. Falls were more common in E (81 %) and vehicle accidents were more common in Y patients (37 %). Acute subdural hematoma was significantly more common in E (50 % of cases) compared to Y patients (18 %). Intracranial pressure was monitored in 44 % of E and 57 % of Y patients. Evacuation of significant mass lesions was performed more common in the E group. The NIC mortality was similar in both groups (4-6 %). Favorable outcome was observed in 72 % of Y and 51 % of E patients. At the time of follow-up 25 % of E and 7 % of Y patients had died.

CONCLUSIONS

The outcome of elderly patients with TBI was significantly worse than in younger patients, as expected. However, as much as 51 % of the elderly patients showed a favorable outcome after NIC. We believe that these results encourage modern NIC in elderly patients with TBI. We need to study how secondary brain injury mechanisms differ in the older patients and to identify specific outcome predictors for elderly patients with TBI.

Predictors of Outcomes in Traumatic Brain Injury

INTRODUCTION

The purpose of this study was to retrospectively evaluate patients treated for traumatic brain injuries (TBI) to determine how multiple organ trauma (MOT) and lung injuries sustained at the time of initial injury affect outcome.

METHODS

A single institution retrospective review of all patients diagnosed with TBI at a level I trauma center from 2000 to 2014 was conducted. Clinical outcome was based on Glasgow Outcome Scale at hospital discharge. Lung injury was defined as the presence of pulmonary contusions, pneumothorax, hemothorax, rib fractures, or diaphragmatic rupture proven by x-ray or computed tomography scan. MOT was defined as trauma to one body region with an Abbreviated Injury Scale (AIS) score ≥3 plus trauma to 2 additional body regions with AIS scores ≥1. Regression analysis was conducted with SPSS 21.

RESULTS

There were 409 patients reviewed. The majority of patients were male (73%), average age was 46 years (range, 16-94 years), average Glasgow Coma Scale (GCS) score was 7, and 71% had a severe TBI (GCS ≤8). Thirty percent of patients had poor outcome (Glasgow Outcome Scale = 1-2) Regression analysis indicated age (odds ratio [OR] 1.03, P < 0.001), initial GCS (OR 0.88, P < 0.001), Injury Severity Score (OR 1.03, P = 0.021), and head AIS ≥5 (OR 0.55, P = 0.019) were significant independent predictors of poor outcome. Sex, MOT, lung injury, and lung injury severity were not significant predictors of outcome.

CONCLUSIONS

Age, GCS, Injury Severity Score, and critical head injuries (AIS ≥5) were significant tools in predicting outcome in this patient cohort. MOT and traumatic lung injury may cause significant damage to a patient suffering from a severe TBI, but these injuries do not predict mortality in this patient population.

Time Course of Coagulation and Fibrinolytic Parameters in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) has long been associated with coagulopathy; however, the time course of coagulation/fibrinolytic parameters in the acute phase of TBI remains unclear. The purpose of the study was to analyze the time course of coagulation/fibrinolytic parameters in the acute phase of TBI and to elucidate parameter relationships to prognosis. We retrospectively evaluated 234 patients with severe isolated TBI with initial blood samples obtained no more than 1 h after injury. Platelet count, prothrombin time, activated partial thromboplastin time (aPTT), plasma levels of fibrinogen, and D-dimer were measured on arrival in the emergency department and 3, 6, and 12 h after injury. Multivariate logistic regression analysis was performed to identify risk factors for poor prognosis at each time point. From hospital admission to 12 h after injury, an elevated D-dimer level was a significant negative prognostic indicator (admission: p < 0.0001; 3 h after injury: p = 0.0005; 6 h after injury: p = 0.005; 12 h after injury: p = 0.0009). An upward trend of aPTT on admission and 3 h after injury was also a significant negative prognostic indicator (admission: p = 0.0011; 3 h after injury: p = 0.013). On multivariate logistic regression analysis, which included all initial variables, independent risk factors for poor prognosis included older age (p = 0.0005), low Glasgow Coma Scale score (p < 0.0001), high Abbreviated Injury Score (p = 0.015), aPTT >30.2 sec (p = 0.019), and elevated D-dimer level (p = 0.0005). We concluded that D-dimer is the best coagulation/fibrinolytic parameter to monitor for prediction of outcome.

Recent trends in hospitalization and in-hospital mortality associated with traumatic brain injury in Canada: A nationwide, population-based study

BACKGROUND

Traumatic brain injury (TBI) is the leading cause of traumatic death and disability worldwide.We examined nationwide trends in TBI-related hospitalizations and in-hospital mortality between April 2006 and March 2011 using a nationwide, population based database that is mandatory for all hospitals in Canada.

METHODS

Trends in hospitalization rates for all acute hospital separations in Canada were analyzed using linear regression. Independent predictors of in-hospital mortality were evaluated using logistic regression.

RESULTS

Hospitalization rates remained stable for children and young adults but increased considerably among elderly adults (age Q65 years). Falls and motor vehicle collisions (MVCs) were the most common causes of TBI hospitalizations. TBIs caused by falls increased by 24% (p = 0.01), while MVC-related hospitalization rates decreased by 18% (p = 0.03). Elderly adults were most vulnerable to falls and experienced the greatest increase (29%) in fall-related hospitalization rates. Young adults (ages, 15Y24 years) were most at risk for MVCs but experienced the greatest decline (28%) in MVC-related admissions. There were significant trends toward increasing age, injury severity, comorbidity, hospital length of stay, and rate of in-hospital mortality.However, multivariate regression showed that odds of death decreased over time after controlling for relevant factors. Injury severity, comorbidity, and advanced age were the most important predictors of in-hospital mortality for TBI inpatients.

CONCLUSION

Hospitalizations for TBI are increasing in severity and involve older populations with more complex comorbidities. Although preventive strategies for MVC-related TBI are likely having some effects, there is a critical need for effective fall prevention strategies, especially among elderly adults.

Clinical Analysis of Delayed Surgical Epidural Hematoma

Objective

A small epidural hematoma (EDH) that has been diagnosed to be nonsurgical by initial brain computed tomography (CT) can increase in size and need surgical removal, resulting in a poor prognosis. However, there have been few studies, which focused delayed operated EDH. Therefore, we analyzed the clinical factors to determine the predicting factors of delayed operated EDH.

Methods

Between January 2011 and January 2014, 90 patients, who were admitted due to EDH, were enrolled in this study. None of the patients were indicated for operation initially. Based on the presence of surgery, we classified the patients into a delayed-surgery group (DG) and a non-surgical group (NG). Additionally, we analyzed them according to the following: time interval between the trauma and the initial CT, gender, age, medical history, drinking, change of mean arterial pressure (MAP), volume of EDH and other traumatic brain lesion.

Results

Among the 90 patients, the DG was 19 patients. Compared with NG, the DG revealed increased MAP, less presence of drinking, and a short time interval (DG vs. NG: +9.684 mm Hg vs. -0.428 mm Hg, 5.26% vs. 29.58%, 1.802 hours vs. 5.707 hours, respectively, p<0.05). Analyzing the time interval with receiver operating characteristic, there was 88.2% sensitivity and 68.3% specificity at the 2.05-hour cut-off value (area under the curve=0.854).

Conclusion

According to our results, the time interval between the trauma and the initial CT along with blood pressure change are potential predicting factors in the cases of delayed operation of EDH.

Influence of Age on Cerebral Housekeeping Gene Expression for Normalization of Quantitative Polymerase Chain Reaction after Acute Brain Injury in Mice

To prevent methodological errors of quantitative PCR (qPCR) normalization with reference genes is obligatory. Although known to influence gene expression, impact of age on housekeeping gene expression has not been determined after acute brain lesions such as traumatic brain injury (TBI). Therefore, expression of eight common control genes was investigated at 15 min, 24 h, and 72 h after experimental TBI in 2- and 21-month-old C57Bl6 mice. Expression of β2-microglobulin (B2M), β-actin (ActB), and porphobilinogen deaminase (PBGD) increased after TBI in both ages. β2M demonstrated age-dependent differences and highest inter- and intragroup variations. Expression of cyclophilin A, glyceraldehyde-3-phosphate dehydrogenase (GAPDH), hypoxanthine ribosyltransferase (HPRT), S100B, and 18SrRNA remained stable. Cyclophilin A and HPRT demonstrated strongest inter- and intragroup stability. The data indicate that the expression of most but not all control genes is stable during aging. The correct choice of housekeeping genes is of key importance to ensure adequate normalization of qPCR data. With respect to insult and age, normalization strategies should consider cyclophilin A as a single normalizer. Normalization with two reference genes is recommended with cyclophilin A and HPRT in young mice and in mixed age studies and with cyclophilin A and GAPDH in old mice. In addition, the present study suggests not to use β2-microglobulin, β-actin or PBGD as single control genes because of strong regulation after CCI in 2- and 21-month-old mice.

Increased in-hospital mortality following severe head injury in young children: results from a nationwide trauma registry

BACKGROUND

In the current literature, the outcome of paediatric brain injury is controversially discussed. According to the majority of the studies, there seems to be a decreased mortality but worse recovery in paediatric, traumatic brain injury in comparison with adults. However, there is a lack of information concerning the differences in various stages of development in patients younger than 18 years. The aim of our study was to verify the in-hospital outcome of different paediatric age groups in comparison to adults with respect to the treatment strategy.

METHODS

We performed a retrospective analysis of the TraumaRegister DGU(®) from 2002 to 2012. Inclusion criteria were an Abbreviated Injury Scale (AIS) head ≥3 points and an AIS ≤2 points of the remaining body regions. The collective was divided into different subgroups according to age (1-3, 4-6, 7-10, 11-14, 15-17) and an adult control group aged between 18 and 55 years. We descriptively analysed the endpoint rate of sepsis, multiple organ failure, and mortality. Additionally, the Glasgow Outcome Scale (GOS) at discharge was observed.

RESULTS

Overall, 1110 children and 6491 adult control patients were included. Comparing the rate of intubation on-scene, the rate of cranial CT scans, the rate of craniotomies, and the rate and length of intensive care treatment, we could only identify minor differences between the age groups. The treatment after discharge from hospital was markedly different due to a very low rate of in-patient rehabilitation treatment in children. On one hand, the rate of systemic complications, such as sepsis and multiple organ failure increased with increasing age. On the other hand, we found a significantly increased mortality in children younger than 7 years after very (AIS head = 5) severe brain injury. The in-hospital functional outcome in survivors, according to the GOS, was beneficial for younger children in comparison to adolescents and adults.

CONCLUSIONS

We were unable to identify marked age-related differences in the therapeutic approach. Nevertheless, we were able to demonstrate marked differences of outcome. Children younger than 7 years significantly die more often due to direct impact of severe trauma. But if they survive, they seem to develop less systemic complications and profit from a better functional outcome.

Severe leukoaraiosis portends a poor outcome after traumatic brain injury

BACKGROUND AND PURPOSE

It is now well accepted that traumatic white matter injury constitutes a critical determinant of post-traumatic functional impairment. However, the contribution of preexisting white matter rarefaction on outcome following traumatic brain injury (TBI) is unknown. Hence, we sought to determine whether the burden of preexisting leukoaraiosis of presumed ischemic origin is independently associated with outcome after TBI.

METHODS

We retrospectively analyzed consecutive, prospectively enrolled patients of ≥50 years (n = 136) who were admitted to a single neurological/trauma intensive care unit. Supratentorial white matter hypoattenuation on head CT was graded on a 5-point scale (range 0-4) reflecting increasing severity of leukoaraiosis. Outcome was ascertained according to the modified Rankin Scale (mRS) and Glasgow outcome scale (GOS) at 3 and 12 months, respectively.

RESULTS

After adjustment for other factors, leukoaraiosis severity was significantly associated with a poor outcome at 3 and 12 months defined as mRS 3-6 and GOS 1-3, respectively. The independent association between leukoaraiosis and poor outcome remained when the analysis was restricted to patients who survived up to 3 months, had moderate-to-severe TBI [enrollment Glasgow Coma Scale (GCS) ≤12; p = 0.001], or had mild TBI (GCS 13-15; p = 0.002), respectively.

CONCLUSION

We provide first evidence that preexisting cerebral small vessel disease independently predicts a poor functional outcome after closed head TBI. This association is independent of other established outcome predictors such as age, comorbid state as well as intensive care unit complications and interventions. This knowledge may help improve prognostic accuracy, clinical management, and resource utilization.