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Cáceres E, Divani AA, Rubinos CA, Olivella-Gómez J, Viñan Garcés AE, González A, Alvarado Arias A, Bhatia K, Samadani U, Reyes LF. PaCO 2 Association with Outcomes of Patients with Traumatic Brain Injury at High Altitude: A Prospective Single-Center Cohort Study. Neurocrit Care 2024:10.1007/s12028-024-01982-8. [PMID: 38740704 DOI: 10.1007/s12028-024-01982-8] [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: 01/18/2024] [Accepted: 03/12/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Partial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes. METHODS This is a prospective single-center cohort of consecutive patients with TBI admitted to a trauma center located at 2600 m above sea level. An unfavorable outcome was defined as a Glasgow Outcome Scale-Extended (GOSE) score < 4 at the 6-month follow-up. RESULTS We had a total of 81 patients with complete data, 80% (65/81) were men, and the median (interquartile range) age was 36 (25-50) years. Median Glasgow Coma Scale (GCS) score on admission was 9 (6-14); 49% (40/81) of patients had severe TBI (GCS 3-8), 32% (26/81) had moderate TBI (GCS 12-9), and 18% (15/81) had mild TBI (GCS 13-15). The median (interquartile range) Abbreviated Injury Score of the head (AISh) was 3 (2-4). The frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), the median GOSE was 4 (2-5), and the median 6-month mortality rate was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, (median age 49 [30-72] vs. 29 [22-41] years, P < 0.01), had lower admission GCS scores (6 [4-8] vs. 13 [8-15], P < 0.01), had higher AISh scores (4 [4-4] vs. 3 [2-4], P < 0.01), had higher Acute Physiology and Chronic Health disease Classification System II scores (17 [15-23] vs. 10 [6-14], P < 0.01), had higher Charlson scores (0 [0-2] vs. 0 [0-0], P < 0.01), and had higher PaCO2 levels (mean 35 ± 8 vs. 32 ± 6 mm Hg, P < 0.01). In a multivariate analysis, age (odds ratio [OR] 1.14, 95% confidence interval [CI] 1.1-1.30, P < 0.01), AISh (OR 4.7, 95% CI 1.55-21.0, P < 0.05), and PaCO2 levels (OR 1.23, 95% CI 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4, 95% CI 1.61-28.5, P = 0.017) and PaCO2 levels (OR 1.36, 95% CI 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome. CONCLUSIONS Higher PaCO2 levels are associated with an unfavorable outcome in ventilated patients with TBI. These results underscore the importance of PaCO2 levels in patients with TBI and whether it should be adjusted for populations living at higher altitudes.
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Affiliation(s)
- Eder Cáceres
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chía, Colombia.
- Department of Bioscience, School of Engineering, Universidad de La Sabana, Chía, Colombia.
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia.
| | - Afshin A Divani
- Department of Neurology, The University of New Mexico, Albuquerque, NM, USA
| | - Clio A Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, NC, USA
| | - Juan Olivella-Gómez
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Angélica González
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
| | | | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA
| | - Uzma Samadani
- Department of Neurosurgery, Minneapolis VA Health Care System, Minneapolis, MN, USA
| | - Luis F Reyes
- Unisabana Center for Translational Science, School of Medicine, Universidad de La Sabana, Chía, Colombia
- Department of Critical Care, Clínica Universidad de La Sabana, Chía, Colombia
- Pandemic Sciences Institute, University of Oxford, Oxford, UK
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Vande Vyvere T, Pisică D, Wilms G, Claes L, Van Dyck P, Snoeckx A, van den Hauwe L, Pullens P, Verheyden J, Wintermark M, Dekeyzer S, Mac Donald CL, Maas AIR, Parizel PM. Imaging Findings in Acute Traumatic Brain Injury: a National Institute of Neurological Disorders and Stroke Common Data Element-Based Pictorial Review and Analysis of Over 4000 Admission Brain Computed Tomography Scans from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2024. [PMID: 38482818 DOI: 10.1089/neu.2023.0553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024] Open
Abstract
In 2010, the National Institute of Neurological Disorders and Stroke (NINDS) created a set of common data elements (CDEs) to help standardize the assessment and reporting of imaging findings in traumatic brain injury (TBI). However, as opposed to other standardized radiology reporting systems, a visual overview and data to support the proposed standardized lexicon are lacking. We used over 4000 admission computed tomography (CT) scans of patients with TBI from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study to develop an extensive pictorial overview of the NINDS TBI CDEs, with visual examples and background information on individual pathoanatomical lesion types, up to the level of supplemental and emerging information (e.g., location and estimated volumes). We documented the frequency of lesion occurrence, aiming to quantify the relative importance of different CDEs for characterizing TBI, and performed a critical appraisal of our experience with the intent to inform updating of the CDEs. In addition, we investigated the co-occurrence and clustering of lesion types and the distribution of six CT classification systems. The median age of the 4087 patients in our dataset was 50 years (interquartile range, 29-66; range, 0-96), including 238 patients under 18 years old (5.8%). Traumatic subarachnoid hemorrhage (45.3%), skull fractures (37.4%), contusions (31.3%), and acute subdural hematoma (28.9%) were the most frequently occurring CT findings in acute TBI. The ranking of these lesions was the same in patients with mild TBI (baseline Glasgow Coma Scale [GCS] score 13-15) compared with those with moderate-severe TBI (baseline GCS score 3-12), but the frequency of occurrence was up to three times higher in moderate-severe TBI. In most TBI patients with CT abnormalities, there was co-occurrence and clustering of different lesion types, with significant differences between mild and moderate-severe TBI patients. More specifically, lesion patterns were more complex in moderate-severe TBI patients, with more co-existing lesions and more frequent signs of mass effect. These patients also had higher and more heterogeneous CT score distributions, associated with worse predicted outcomes. The critical appraisal of the NINDS CDEs was highly positive, but revealed that full assessment can be time consuming, that some CDEs had very low frequencies, and identified a few redundancies and ambiguity in some definitions. Whilst primarily developed for research, implementation of CDE templates for use in clinical practice is advocated, but this will require development of an abbreviated version. In conclusion, with this study, we provide an educational resource for clinicians and researchers to help assess, characterize, and report the vast and complex spectrum of imaging findings in patients with TBI. Our data provides a comprehensive overview of the contemporary landscape of TBI imaging pathology in Europe, and the findings can serve as empirical evidence for updating the current NINDS radiologic CDEs to version 3.0.
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Affiliation(s)
- Thijs Vande Vyvere
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Dana Pisică
- Department of Neurosurgery, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Public Health, Erasmus MC - University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Guido Wilms
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - Lene Claes
- icometrix, Research and Development, Leuven, Belgium
| | - Pieter Van Dyck
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Annemiek Snoeckx
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Molecular Imaging and Radiology (MIRA), Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Luc van den Hauwe
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
| | - Pim Pullens
- Department of Imaging, University Hospital Ghent; IBITech/MEDISIP, Engineering and Architecture, Ghent University; Ghent Institute for Functional and Metabolic Imaging, Ghent University, Belgium
| | - Jan Verheyden
- icometrix, Research and Development, Leuven, Belgium
| | - Max Wintermark
- Department of Neuroradiology, University of Texas MD Anderson Center, Houston, Texas, USA
| | - Sven Dekeyzer
- Department of Radiology, Antwerp University Hospital, Antwerp, Belgium
- Department of Radiology, University Hospital Ghent, Belgium
| | - Christine L Mac Donald
- Department of Neurological Surgery, School of Medicine, Harborview Medical Center, Seattle, Washington, USA
- Department of Neurological Surgery, School of Medicine, University of Washington, Seattle, Washington, USA
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Antwerp, Belgium
- Department of Translational Neuroscience, Faculty of Medicine and Health Science, University of Antwerp, Antwerp, Belgium
| | - Paul M Parizel
- Department of Radiology, Royal Perth Hospital (RPH) and University of Western Australia (UWA), Perth, Australia; Western Australia National Imaging Facility (WA NIF) node, Australia
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Caceres E, Divani AA, Rubinos CA, Olivella-Gómez J, Viñán-Garcés AE, González A, Alvarado-Arias A, Bathia K, Samadani U, Reyes LF. PaCO2 Association with Traumatic Brain Injury Patients Outcomes at High Altitude: A Prospective Single-Center Cohort Study. RESEARCH SQUARE 2024:rs.3.rs-3876988. [PMID: 38343855 PMCID: PMC10854293 DOI: 10.21203/rs.3.rs-3876988/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
Background partial pressure of carbon dioxide (PaCO2) is generally known to influence outcome in patients with traumatic brain injury (TBI) at normal altitudes. Less is known about specific relationships of PaCO2 levels and clinical outcomes at high altitudes. Methods This is a prospective single-center cohort of consecutive TBI patients admitted to a trauma center located at 2600 meter above sea level. An unfavorable outcome was defined as the Glasgow Outcome Scale-Extended (GOSE) < 4 at 6-month follow-up. Results 81 patients with complete data, 80% (65/81) were men, and median (IQR) age was 36 (25-50) years). Median Glasgow Coma Scale (GCS) on admission was 9 (6-14), 49% (40/81) were severe (GCS: 3-8), 32% (26/81) moderate (GCS 12 - 9), and 18% (15/81) mild (GCS 13-15) TBI. The median (IQR) Abbreviated Injury Score of the Head (AISh) was 3 (2-4). Frequency of an unfavorable outcome (GOSE < 4) was 30% (25/81), median GOSE was 4 (2-5), and 6-month mortality was 24% (20/81). Comparison between patients with favorable and unfavorable outcomes revealed that those with unfavorable outcome were older, median [49 (30-72) vs. 29 (22-41), P < 0.01], had lower admission GCS [6 (4-8) vs. 13 (8-15), P < 0.01], higher AIS head [4 (4-4) vs. 3(2-4), p < 0.01], higher APACHE II score [17(15-23) vs 10 (6-14), < 0.01), higher Charlson score [0(0-2) vs. 0 (0-0), P < 0.01] and higher PaCO2 (mmHg), mean ± SD, 39 ± 9 vs. 32 ± 6, P < 0.01. In a multivariate analysis, age (OR 1.14 95% CI 1.1-1.30, P < 0.01), AISh (OR 4.7 95% CI 1.55-21.0, P < 0.05), and PaCO2 (OR 1.23 95% CI: 1.10-1.53, P < 0.05) were significantly associated with the unfavorable outcomes. When applying the same analysis to the subgroup on mechanical ventilation, AISh (OR 5.4 95% CI: 1.61-28.5, P = 0.017) and PaCO2 (OR 1.36 95% CI: 1.13-1.78, P = 0.015) remained significantly associated with the unfavorable outcome. Conclusion Higher PaCO2 levels are associated with an unfavorable outcome in ventilated TBI patients. These results underscore the importance of PaCO2 level in TBI patients and whether it should be adjusted for populations living at higher altitudes.
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Affiliation(s)
| | - Afshin A Divani
- University of New Mexico - Albuquerque: The University of New Mexico
| | - Clio A Rubinos
- University of North Carolina at Chapel Hill Health Sciences Library: The University of North Carolina at Chapel Hill
| | | | | | | | - Alexis Alvarado-Arias
- University of Mississippi University Hospital: The University of Mississippi Medical Center
| | - Kunal Bathia
- University of Mississippi University Hospital: The University of Mississippi Medical Center
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Gelormini C, Ioannoni E, Scavone A, Pisapia L, Signorelli F, Montano N, Piastra M, Caricato A. Hyperemia in head injury: can transcranial doppler help to personalize therapies for intracranial hypertension? Front Neurol 2023; 14:1259180. [PMID: 38033776 PMCID: PMC10686491 DOI: 10.3389/fneur.2023.1259180] [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: 07/15/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction An increase in cerebral blood flow is frequent after traumatic brain injury (TBI) and can lead to brain swelling and refractory intracranial hypertension. We hypothesized that Transcranial EcoDoppler (TCD) monitoring could be useful to detect the cause of intracranial hypertension in these patients. Our main objective was to investigate if the increase of velocity in the middle cerebral artery (MCA) on TCD could be associated with intracranial hypertension. Methods We retrospectively studied TBI patients consecutively monitored with TCD. Hyperemia was defined as MCA mean velocity higher than 80 cm/s. Intracranial hypertension was considered when hyperosmolar therapy, hyperventilation, or deep sedation was used. Results We found hyperemia in 40 patients out of 118 (33.9%). On average, it started at day 2.1 ± 0.9 from admission and significantly increased (MCA velocity at day 1: 74 ± 25 cm/s vs. 109 ± 36 cm/s at day 4; p < 0.001). Intracranial hypertension was significantly associated with hyperemia, occurring in 92.5% of hyperemic and 51.3% of non-hyperemic patients (p < 0.001). Moreover, we found that hyperemia preceded severe intracranial hypertension (p < 0.0001). In a logistic regression model, hyperemia was the only variable significantly correlated with intracranial hypertension (OR 10.64; p < 0.001). Discussion Hyperemia was frequent in our population of TBI patients and preceded intracranial hypertension. TCD monitoring, if performed on a daily regular basis, can be a useful method to detect this phenomenon and to guide the therapy. It could be a tool for a cause-oriented therapy of intracranial hypertension.
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Affiliation(s)
- Camilla Gelormini
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Eleonora Ioannoni
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Angela Scavone
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Luca Pisapia
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Francesco Signorelli
- Neurosurgery Section, Department of Neuroscience, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Nicola Montano
- Neurosurgery Section, Department of Neuroscience, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
- Neurosurgery Section, Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Piastra
- Pediatric ICU and Trauma Center, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anselmo Caricato
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
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Payen JF, Launey Y, Chabanne R, Gay S, Francony G, Gergele L, Vega E, Montcriol A, Couret D, Cottenceau V, Pili-Floury S, Gakuba C, Hammad E, Audibert G, Pottecher J, Dahyot-Fizelier C, Abdennour L, Gauss T, Richard M, Vilotitch A, Bosson JL, Bouzat P. Intracranial pressure monitoring with and without brain tissue oxygen pressure monitoring for severe traumatic brain injury in France (OXY-TC): an open-label, randomised controlled superiority trial. Lancet Neurol 2023; 22:1005-1014. [PMID: 37863590 DOI: 10.1016/s1474-4422(23)00290-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Optimisation of brain oxygenation might improve neurological outcome after traumatic brain injury. The OXY-TC trial explored the superiority of a strategy combining intracranial pressure and brain tissue oxygen pressure (PbtO2) monitoring over a strategy of intracranial pressure monitoring only to reduce the proportion of patients with poor neurological outcome at 6 months. METHODS We did an open-label, randomised controlled superiority trial at 25 French tertiary referral centres. Within 16 h of brain injury, patients with severe traumatic brain injury (aged 18-75 years) were randomly assigned via a website to be managed during the first 5 days of admission to the intensive care unit either by intracranial pressure monitoring only or by both intracranial pressure and PbtO2 monitoring. Randomisation was stratified by age and centre. The study was open label due to the visibility of the intervention, but the statisticians and outcome assessors were masked to group allocation. The therapeutic objectives were to maintain intracranial pressure of 20 mm Hg or lower, and to keep PbtO2 (for those in the dual-monitoring group) above 20 mm Hg, at all times. The primary outcome was the proportion of patients with an extended Glasgow Outcome Scale (GOSE) score of 1-4 (death to upper severe disability) at 6 months after injury. The primary analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew consent or had protocol violations. This trial is registered with ClinicalTrials.gov, NCT02754063, and is completed. FINDINGS Between June 15, 2016, and April 17, 2021, 318 patients were randomly assigned to receive either intracranial pressure monitoring only (n=160) or both intracranial pressure and PbtO2 monitoring (n=158). 27 individuals with protocol violations were not included in the modified intention-to-treat analysis. Thus, the primary outcome was analysed for 144 patients in the intracranial pressure only group and 147 patients in the intracranial pressure and PbtO2 group. Compared with intracranial pressure monitoring only, intracranial pressure and PbtO2 monitoring did not reduce the proportion of patients with GOSE score 1-4 (51% [95% CI 43-60] in the intracranial pressure monitoring only group vs 52% [43-60] in the intracranial pressure and PbtO2 monitoring group; odds ratio 1·0 [95% CI 0·6-1·7]; p=0·95). Two (1%) of 144 participants in the intracranial pressure only group and 12 (8%) of 147 participants in the intracranial pressure and PbtO2 group had catheter dysfunction (p=0.011). Six patients (4%) in the intracranial pressure and PbtO2 group had an intracrebral haematoma related to the catheter, compared with none in the intracranial pressure only group (p=0.030). No significant difference in deaths was found between the two groups at 12 months after injury. At 12 months, 33 deaths had occurred in the intracranial pressure group: 25 (76%) were attributable to the brain trauma, six (18%) were end-of-life decisions, and two (6%) due to sepsis. 34 deaths had occured in the intracranial pressure and PbtO2 group at 12 months: 25 (74%) were attributable to the brain trauma, six (18%) were end-of-life decisions, one (3%) due to pulmonary embolism, one (3%) due to haemorrhagic shock, and one (3%) due to cardiac arrest. INTERPRETATION After severe non-penetrating traumatic brain injury, intracranial pressure and PbtO2 monitoring did not reduce the proportion of patients with poor neurological outcome at 6 months. Technical failures related to intracerebral catheter and intracerebral haematoma were more frequent in the intracranial pressure and PbtO2 group. Further research is needed to assess whether a targeted approach to multimodal brain monitoring could be useful in subgroups of patients with severe traumatic brain injury-eg, those with high intracranial pressure on admission. FUNDING The French National Program for Clinical Research, La Fondation des Gueules Cassées, and Integra Lifesciences.
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Affiliation(s)
- Jean-François Payen
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France.
| | - Yoann Launey
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Russell Chabanne
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Samuel Gay
- Department of Intensive Care, Centre Hospitalier Annecy Genevois, Annecy, France
| | - Gilles Francony
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Laurent Gergele
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Saint-Etienne, Saint-Etienne, France
| | - Emmanuel Vega
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Lille, Lille, France
| | - Ambroise Montcriol
- Department of Intensive Care, Hopital Instruction des Armées Saint-Anne, Toulon, France
| | - David Couret
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Sud, Reunion, France
| | - Vincent Cottenceau
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - Sebastien Pili-Floury
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Besançon, Besançon, France
| | - Clement Gakuba
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Caen Normandie, Caen, France
| | - Emmanuelle Hammad
- Department of Anaesthesia and Intensive Care, Hôpital Nord, Assistance Publique des Hopitaux de Marseille, Marseille, France
| | - Gerard Audibert
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Nancy, Nancy, France
| | - Julien Pottecher
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Strasbourg, Strasbourg, France
| | - Claire Dahyot-Fizelier
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Poitiers, Poitiers, France
| | - Lamine Abdennour
- Department of Anaesthesia and Intensive Care, Hôpital Pitie-Salpetriere, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Tobias Gauss
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Marion Richard
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Antoine Vilotitch
- Department of Public Health, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France
| | - Jean-Luc Bosson
- Department of Public Health, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France
| | - Pierre Bouzat
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
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Lazaridis C, Foreman B. Management Strategies Based on Multi-Modality Neuromonitoring in Severe Traumatic Brain Injury. Neurotherapeutics 2023; 20:1457-1471. [PMID: 37491682 PMCID: PMC10684466 DOI: 10.1007/s13311-023-01411-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 07/27/2023] Open
Abstract
Secondary brain injury after neurotrauma is comprised of a host of distinct, potentially concurrent and interacting mechanisms that may exacerbate primary brain insult. Multimodality neuromonitoring is a method of measuring multiple aspects of the brain in order to understand the signatures of these different pathomechanisms and to detect, treat, or prevent potentially reversible secondary brain injuries. The most studied invasive parameters include intracranial pressure (ICP), cerebral perfusion pressure (CPP), autoregulatory indices, brain tissue partial oxygen tension, and tissue energy and metabolism measures such as the lactate pyruvate ratio. Understanding the local metabolic state of brain tissue in order to infer pathology and develop appropriate management strategies is an area of active investigation. Several clinical trials are underway to define the role of brain tissue oxygenation monitoring and electrocorticography in conjunction with other multimodal neuromonitoring information, including ICP and CPP monitoring. Identifying an optimal CPP to guide individualized management of blood pressure and ICP has been shown to be feasible, but definitive clinical trial evidence is still needed. Future work is still needed to define and clinically correlate patterns that emerge from integrated measurements of metabolism, pressure, flow, oxygenation, and electrophysiology. Pathophysiologic targets and precise critical care management strategies to address their underlying causes promise to mitigate secondary injuries and hold the potential to improve patient outcome. Advancements in clinical trial design are poised to establish new standards for the use of multimodality neuromonitoring to guide individualized clinical care.
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Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
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Svedung Wettervik T, Beqiri E, Hånell A, Bögli SY, Placek M, Guilfoyle MR, Helmy A, Lavinio A, O'Leary R, Hutchinson PJ, Smielewski P. Brain tissue oxygen monitoring in traumatic brain injury-part II: isolated and combined insults in relation to outcome. Crit Care 2023; 27:370. [PMID: 37752602 PMCID: PMC10523606 DOI: 10.1186/s13054-023-04659-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND The primary aim was to explore the concept of isolated and combined threshold-insults for brain tissue oxygenation (pbtO2) in relation to outcome in traumatic brain injury (TBI). METHODS A total of 239 TBI patients with data on clinical outcome (GOS) and intracranial pressure (ICP) and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke's Hospital, Cambridge, UK, between 2002 and 2022 were included. Outcome was dichotomised into favourable/unfavourable (GOS 4-5/1-3) and survival/mortality (GOS 2-5/1). PbtO2 was studied over the entire monitoring period. Thresholds were analysed in relation to outcome based on median and mean values, percentage of time and dose per hour below critical values and visualised as the combined insult intensity and duration. RESULTS Median pbtO2 was slightly, but not significantly, associated with outcome. A pbtO2 threshold at 25 and 20 mmHg, respectively, yielded the highest x2 when dichotomised for favourable/unfavourable outcome and mortality/survival in chi-square analyses. A higher dose and higher percentage of time spent with pbtO2 below 25 mmHg as well as lower thresholds were associated with unfavourable outcome, but not mortality. In a combined insult intensity and duration analysis, there was a transition from favourable towards unfavourable outcome when pbtO2 went below 25-30 mmHg for 30 min and similar transitions occurred for shorter durations when the intensity was higher. Although these insults were rare, pbtO2 under 15 mmHg was more strongly associated with unfavourable outcome if, concurrently, ICP was above 20 mmHg, cerebral perfusion pressure below 60 mmHg, or pressure reactivity index above 0.30 than if these variables were not deranged. In a multiple logistic regression, a higher percentage of monitoring time with pbtO2 < 15 mmHg was associated with a higher rate of unfavourable outcome. CONCLUSIONS Low pbtO2, under 25 mmHg and particularly below 15 mmHg, for longer durations and in combination with disturbances in global cerebral physiological variables were associated with poor outcome and may indicate detrimental ischaemic hypoxia. Prospective trials are needed to determine if pbtO2-directed therapy is beneficial, at what individualised pbtO2 threshold therapies are warranted, and how this may depend on the presence/absence of concurrent cerebral physiological disturbances.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK.
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Michal Placek
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
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Zhao ZA, Yan L, Wen J, Satyanarayanan SK, Yu F, Lu J, Liu YU, Su H. Cellular and molecular mechanisms in vascular repair after traumatic brain injury: a narrative review. BURNS & TRAUMA 2023; 11:tkad033. [PMID: 37675267 PMCID: PMC10478165 DOI: 10.1093/burnst/tkad033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 02/01/2023] [Accepted: 05/26/2023] [Indexed: 09/08/2023]
Abstract
Traumatic brain injury (TBI) disrupts normal brain function and is associated with high morbidity and fatality rates. TBI is characterized as mild, moderate or severe depending on its severity. The damage may be transient and limited to the dura matter, with only subtle changes in cerebral parenchyma, or life-threatening with obvious focal contusions, hematomas and edema. Blood vessels are often injured in TBI. Even in mild TBI, dysfunctional cerebral vascular repair may result in prolonged symptoms and poor outcomes. Various distinct types of cells participate in vascular repair after TBI. A better understanding of the cellular response and function in vascular repair can facilitate the development of new therapeutic strategies. In this review, we analyzed the mechanism of cerebrovascular impairment and the repercussions following various forms of TBI. We then discussed the role of distinct cell types in the repair of meningeal and parenchyma vasculature following TBI, including endothelial cells, endothelial progenitor cells, pericytes, glial cells (astrocytes and microglia), neurons, myeloid cells (macrophages and monocytes) and meningeal lymphatic endothelial cells. Finally, possible treatment techniques targeting these unique cell types for vascular repair after TBI are discussed.
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Affiliation(s)
- Zi-Ai Zhao
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
- Department of Neurology, General Hospital of Northern Theater Command, 83# Wen-Hua Road, Shenyang 110840, China
| | - Lingli Yan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Jing Wen
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Senthil Kumaran Satyanarayanan
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Feng Yu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Jiahong Lu
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
| | - Yong U Liu
- Laboratory of Neuroimmunology in Health and Disease Institute, Guangzhou First People’s Hospital School of Medicine, South China University of Technology, Guangzhou Higher Education Mega Center, Panyu District, Guangzhou 511400, China
| | - Huanxing Su
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, Macau 999078, China
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Smith G, Thapak P, Paydar A, Ying Z, Gomez-Pinilla F, Harris NG. Altering the Trajectory of Perfusion-Diffusion Deficits Using A BDNF Mimetic Acutely After TBI is Associated with Improved Functional Connectivity. PROGRESS IN NEUROBIOLOGY (DOVER, DEL.) 2023; 10:10.60124/j.pneuro.2023.10.07. [PMID: 38037566 PMCID: PMC10689006 DOI: 10.60124/j.pneuro.2023.10.07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
Traumatic brain injury (TBI) results in metabolic deficits and functionally compromised tissue. The BDNF mimetic R13 has a significant positive effect on both tissue metabolism and behavioral outcome after TBI, indicating a promising therapeutic. To understand the mechanism of action for this intervention, we determined whether there was any association between the underlying metabolic insult and any improvement in resting state functional connectivity (FC) with MRI, or whether R13 acts through mechanisms unrelated to metabolic recovery. We found perfusion deficits could be reasonably approximated by reductions in mean diffusivity (MD) acutely after injury, because a majority of regions with low perfusion matched to regions of low MD, indicative of cell swelling. Injury alone resulted in reduced cross-brain FC and contralateral hyperconnectivity at 1d compared to sham and these were spatially coincident with regions of low MD. R13 intervention at 1-7d altered the tissue trajectory of MD pathology away from pseudo-normalization so that a greater volume of tissue remained with low MD at 7d. These same regions were associated with significant changes in cross-brain and contralateral FC in R13 treated rats compared to injured vehicle-treated rats. These data indicate a likely metabolic effect of R13 acutely after injury.
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Affiliation(s)
- Gregory Smith
- Department of Neurosurgery, UCLA David Geffen School. of Medicine, Los Angeles, California, USA
- UCLA Brain Injury Research Center, Los Angeles, California, USA
| | - Pavan Thapak
- Department of Integrative Biology and Physiology, UCLA, Los Angeles, California, USA
| | - Afshin Paydar
- Department of Neurosurgery, UCLA David Geffen School. of Medicine, Los Angeles, California, USA
- UCLA Brain Injury Research Center, Los Angeles, California, USA
| | - Zhe Ying
- Department of Integrative Biology and Physiology, UCLA, Los Angeles, California, USA
| | - Fernando Gomez-Pinilla
- UCLA Brain Injury Research Center, Los Angeles, California, USA
- Department of Integrative Biology and Physiology, UCLA, Los Angeles, California, USA
| | - Neil G. Harris
- Department of Neurosurgery, UCLA David Geffen School. of Medicine, Los Angeles, California, USA
- UCLA Brain Injury Research Center, Los Angeles, California, USA
- Intellectual and Developmental Disabilities Research Center, UCLA, Los Angeles, California, USA
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10
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Svedung Wettervik T, Beqiri E, Bögli SY, Placek M, Guilfoyle MR, Helmy A, Lavinio A, O'Leary R, Hutchinson PJ, Smielewski P. Brain tissue oxygen monitoring in traumatic brain injury: part I-To what extent does PbtO 2 reflect global cerebral physiology? Crit Care 2023; 27:339. [PMID: 37653526 PMCID: PMC10472704 DOI: 10.1186/s13054-023-04627-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The primary aim was to explore the association of global cerebral physiological variables including intracranial pressure (ICP), cerebrovascular reactivity (PRx), cerebral perfusion pressure (CPP), and deviation from the PRx-based optimal CPP value (∆CPPopt; actual CPP-CPPopt) in relation to brain tissue oxygenation (pbtO2) in traumatic brain injury (TBI). METHODS A total of 425 TBI patients with ICP- and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke's Hospital, Cambridge, UK, between 2002 and 2022 were included. Generalized additive models (GAMs) and linear mixed effect models were used to explore the association of ICP, PRx, CPP, and CPPopt in relation to pbtO2. PbtO2 < 20 mmHg, ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, and ∆CPPopt < - 5 mmHg were considered as cerebral insults. RESULTS PbtO2 < 20 mmHg occurred in median during 17% of the monitoring time and in less than 5% in combination with ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, or ∆CPPopt < - 5 mmHg. In GAM analyses, pbtO2 remained around 25 mmHg over a large range of ICP ([0;50] mmHg) and PRx [- 1;1], but deteriorated below 20 mmHg for extremely low CPP below 30 mmHg and ∆CPPopt below - 30 mmHg. In linear mixed effect models, ICP, CPP, PRx, and ∆CPPopt were significantly associated with pbtO2, but the fixed effects could only explain a very small extent of the pbtO2 variation. CONCLUSIONS PbtO2 below 20 mmHg was relatively frequent and often occurred in the absence of disturbances in ICP, PRx, CPP, and ∆CPPopt. There were significant, but weak associations between the global cerebral physiological variables and pbtO2, suggesting that hypoxic pbtO2 is often a complex and independent pathophysiological event. Thus, other variables may be more crucial to explain pbtO2 and, likewise, pbtO2 may not be a suitable outcome measure to determine whether global cerebral blood flow optimization such as CPPopt therapy is successful.
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Affiliation(s)
- Teodor Svedung Wettervik
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden.
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Michal Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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11
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Song H, Fisher J, Özen AC, Akin B, Schumann S, Bock M. Quantification of regional CMRO 2 in human brain using dynamic 17O-MRI at 3T. Z Med Phys 2023:S0939-3889(23)00086-7. [PMID: 37558527 DOI: 10.1016/j.zemedi.2023.07.004] [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: 03/31/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/11/2023]
Abstract
OBJECTIVE To investigate the feasibility of cerebral metabolic rate of oxygen consumption (CMRO2) measurements with MRI at 3 Tesla in different brain regions. METHODS CMRO2 represents a key indicator of the physiological state of brain tissue. Dynamic 17O-MRI with inhalation of isotopically enriched 17O gas has been used to quantify global CMRO2 in brain white (WM) and gray matter (GM). However, global CMRO2 can only reflect the overall oxygen metabolism of the brain and cannot provide enough information on local tissue oxygen metabolism. To investigate the feasibility of determination of regional CMRO2 at a clinical 3 T MRI system, CMRO2 values in frontal, parietal and occipital WM and GM were determined in 5 healthy volunteers and compared to evaluate the regional differences of oxygen metabolism in WM and GM. Additionally, regional CMRO2 values were determined in deep brain structures including thalamus, dorsal striatum, caudate nucleus and insula cortex and in the cerebella, and compared with literature values from 15O-PET studies. RESULTS In cortical GM the determined CMRO2 values were in good agreement with the literature, whereas values in WM were about 32-48% higher than literature values. Regional analysis revealed a significantly higher CMRO2 in the occipital GM compared to the frontal and parietal GM. By contrast, no significant difference of CMRO2 was observed across the WM. In addition, CMRO2 in deep brain structures was lower compared to literature values and in the cerebella a good hemispheric symmetry of the tissue oxygen metabolism was found. CONCLUSION Dynamic 17O-MRI enables direct, non-invasive determination of regional CMRO2 in brain structures in healthy volunteers at 3T.
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Affiliation(s)
- Hao Song
- Division of Medical Physics, Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Johannes Fisher
- Division of Medical Physics, Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ali Caglar Özen
- Division of Medical Physics, Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Burak Akin
- Section on Functional Imaging Methods, NIMH, NIH, Bethesda, MD, USA
| | - Stefan Schumann
- Department of Anesthesiology and Critical Care, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Michael Bock
- Division of Medical Physics, Department of Diagnostic and Interventional Radiology, University Medical Center Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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12
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Wu Y, Hu Q, Cheng H, Yu J, Gao L, Gao G. USP30 impairs mitochondrial quality control and aggravates oxidative damage after traumatic brain injury. Biochem Biophys Res Commun 2023; 671:58-66. [PMID: 37300943 DOI: 10.1016/j.bbrc.2023.05.069] [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: 05/10/2023] [Accepted: 05/18/2023] [Indexed: 06/12/2023]
Abstract
Clinical progress in the treatment of traumatic brain injury (TBI) is hindered by the poor understanding of the molecular mechanisms that underlie secondary brain injury (SBI). USP30, a mitochondrial deubiquitinase, has been implicated in the pathological progress of various diseases. However, the precise role of USP30 in TBI-induced SBI remains unclear. In this study, we found that USP30 was differentially upregulated after TBI in humans and mice. Immunofluorescence staining further revealed that the enhanced USP30 mainly localized in neurons. Neuron-specific knockout of USP30 reduced lesion volumes, mitigated brain edema, and attenuated neurological deficits after TBI in mice. Additionally, we found that USP30 deficiency effectively suppressed oxidative stress and neuronal apoptosis in TBI. Those protective effects of USP30 loss may be attributed, at least partially, to the reduction of TBI-induced impairment of mitochondrial quality control, including mitochondrial dynamics, function, and mitophagy. Collectively, our findings identify a previously undisclosed role of USP30 in the pathophysiology of TBI and lay a preliminary foundation for future research in this field.
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Affiliation(s)
- Yang Wu
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi province, 710038, China; Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei province, 050000, China
| | - Qing Hu
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi province, 710038, China
| | - Hongbo Cheng
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei province, 050000, China
| | - Jiegang Yu
- Department of Neurosurgery, The Second Hospital of Hebei Medical University, Shijiazhuang, Hebei province, 050000, China
| | - Li Gao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi province, 710038, China.
| | - Guodong Gao
- Department of Neurosurgery, Tangdu Hospital, Fourth Military Medical University, Xi'an, Shaanxi province, 710038, China.
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13
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Denchev K, Gomez J, Chen P, Rosenblatt K. Traumatic Brain Injury: Intraoperative Management and Intensive Care Unit Multimodality Monitoring. Anesthesiol Clin 2023; 41:39-78. [PMID: 36872007 DOI: 10.1016/j.anclin.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Traumatic brain injury is a devastating event associated with substantial morbidity. Pathophysiology involves the initial trauma, subsequent inflammatory response, and secondary insults, which worsen brain injury severity. Management entails cardiopulmonary stabilization and diagnostic imaging with targeted interventions, such as decompressive hemicraniectomy, intracranial monitors or drains, and pharmacological agents to reduce intracranial pressure. Anesthesia and intensive care requires control of multiple physiologic variables and evidence-based practices to reduce secondary brain injury. Advances in biomedical engineering have enhanced assessments of cerebral oxygenation, pressure, metabolism, blood flow, and autoregulation. Many centers employ multimodality neuromonitoring for targeted therapies with the hope to improve recovery.
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Affiliation(s)
- Krassimir Denchev
- Department of Anesthesiology, Wayne State University, 44555 Woodward Avenue, SJMO Medical Office Building, Suite 308, Pontiac, MI 48341, USA
| | - Jonathan Gomez
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA
| | - Pinxia Chen
- Department of Anesthesiology and Critical Care Medicine, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, USA
| | - Kathryn Rosenblatt
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA; Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA.
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14
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Patient-Centered Approaches to Cognitive Assessment in Acute TBI. Curr Neurol Neurosci Rep 2023; 23:59-66. [PMID: 36705882 DOI: 10.1007/s11910-023-01253-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2023] [Indexed: 01/28/2023]
Abstract
PURPOSE OF THE REVIEW The purpose of this article is to help clinicians understand how underlying pathophysiologies and medical comorbidities associated with acute traumatic brain injury (TBI) can impact assessment of cognition during the initial stages of recovery. Clinicians can use information from this article to develop assessment plans rooted in patient-centered care. RECENT FINDINGS The authors conducted a review of the literature related to the assessment of cognition in acute TBI, focusing on pathophysiology, medical comorbidities, and assessment approaches. Results indicated that TBI pathophysiologies associated with white and gray matter changes make many patients vulnerable to cognitive deficits. Acute comorbidities such as psychological and pain status influence cognitive abilities as well. The current approaches to cognitive assessment can be limited in many ways, though by using the patient's neuropathological profile, noted comorbidities, and other patient specific factors, clinicians can potentially improve the effectiveness of assessment.
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15
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Avoiding brain hypoxia in severe traumatic brain injury in settings with limited resources - A pathophysiological guide. J Crit Care 2023; 75:154260. [PMID: 36773368 DOI: 10.1016/j.jcrc.2023.154260] [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: 07/15/2022] [Revised: 12/17/2022] [Accepted: 01/22/2023] [Indexed: 02/11/2023]
Abstract
Cerebral oxygenation represents the balance between oxygen delivery, consumption and utilization by the brain, and therefore reflects the adequacy of cerebral perfusion. Different factors can influence the amount of oxygen to the brain including arterial blood pressure, hemoglobin levels, systemic oxygenation, and transfer of oxygen from blood to the cerebral microcirculation. A mismatch between cerebral oxygen supply and demand results in cerebral hypoxia/ischemia, and is associated with secondary brain damage and worsened outcome after acute brain injury. Therefore, monitoring and prompt treatment of cerebral oxygenation compromise is warranted in both neuro and general intensive care unit populations. Several tools have been proposed for the assessment of cerebral oxygenation, including non-invasive/invasive or indirect/direct methods, including Jugular Venous Oxygen Saturation (SjO2), Partial Brain Tissue Oxygen Tension (PtiO2), Near infrared spectroscopy (NIRS), Transcranial Doppler, electroencephalography and Computed Tomography. In this manuscript, we aim to review the pathophysiology of cerebral oxygenation, describe monitoring technics, and generate recommendations for avoiding brain hypoxia in settings with low availability of resources for direct brain oxygen monitoring.
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16
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Meyer S, Hummel R, Neulen A, Hirnet T, Thal SC. Influence of traumatic brain injury on ipsilateral and contralateral cortical perfusion in mice. Neurosci Lett 2023; 795:137047. [PMID: 36603737 DOI: 10.1016/j.neulet.2023.137047] [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: 09/20/2022] [Revised: 11/28/2022] [Accepted: 01/01/2023] [Indexed: 01/04/2023]
Abstract
Traumatic brain injury (TBI) is one of the most important causes of death in young adults. After brain injury cortical perfusion is impaired by cortical spreading depression, cerebral microvasospasm or microvascular thrombosis and contributes to secondary expansion of lesion into surrounding healthy brain tissue. The present study was designed to determine the regional cortical perfusion pattern after experimental TBI induced by controlled cortical impact (CCI) in male C57/BL6N mice. We performed a longitudinal time series analysis by Laser speckle contrast imaging (LSCI). Measurements were carried out before, immediately and 24 h after trauma. Immediately after CCI cortical perfusion in the lesion core dropped to 10 % of before injury (baseline; %BL) and to 21-24 %BL in the cortical area surrounding the core. Interestingly, cortical perfusion was also significantly reduced in the contralateral non-injured hemisphere (41-58 %BL) matching the corresponding brain region of the injured hemisphere. 24 h after CCI perfusion of the contralateral hemisphere returned to baseline level in the area corresponding to the lesion core, whereas the lateral area of the parietal cortex was hyperperfused (125 %BL). The lesion core region itself remained severely hypoperfused (18 to 26 %BL) during the observation period. TBI causes a maldistribution of both ipsi- and contralateral cerebral perfusion immediately after trauma, which persist for at least 24 h. Higher perfusion levels in the lesion core 24 h after trauma were associated with increased tissue damage, which supports the role of reperfusion injury for secondary brain damage after TBI.
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Affiliation(s)
- Simon Meyer
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Regina Hummel
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Tobias Hirnet
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany.
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstraße 1, 55131 Mainz, Germany; Department of Anesthesiology, HELIOS University Hospital Wuppertal, University Witten/Herdecke, Heusnerstraße 40, 42283 Wuppertal, Germany.
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17
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Sharma H, McGinnis JP, Kabotyanski KE, Gopinath SP, Goodman JC, Robertson C, Cruz Navarro J. Cerebral microdialysis and glucopenia in traumatic brain injury: A review. Front Neurol 2023; 14:1017290. [PMID: 36779054 PMCID: PMC9911651 DOI: 10.3389/fneur.2023.1017290] [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: 08/11/2022] [Accepted: 01/09/2023] [Indexed: 01/28/2023] Open
Abstract
Traditionally, intracranial pressure (ICP) and partial brain tissue oxygenation (PbtO2) have been the primary invasive intracranial measurements used to guide management in patients with severe traumatic brain injury (TBI). After injury however, the brain develops an increased metabolic demand which may require an increment in the oxidative metabolism of glucose. Simultaneously, metabolic, and electrical dysfunction can lead to an inability to meet these demands, even in the absence of ischemia or increased intracranial pressure. Cerebral microdialysis provides the ability to accurately measure local concentrations of various solutes including lactate, pyruvate, glycerol and glucose. Experimental and clinical data demonstrate that such measurements of cellular metabolism can yield critical missing information about a patient's physiologic state and help limit secondary damage. Glucose management in traumatic brain injury is still an unresolved question. As cerebral glucose metabolism may be uncoupled from systemic glucose levels due to the metabolic dysfunction, measurement of cerebral extracellular glucose concentrations could provide more predictive information and prove to be a better biomarker to avoid secondary injury of at-risk brain tissue. Based on data obtained from cerebral microdialysis, specific interventions such as ICP-directed therapy, blood glucose increment, seizure control, and/or brain oxygen optimization can be instituted to minimize or prevent secondary insults. Thus, microdialysis measurements of parenchymal metabolic function provides clinically valuable information that cannot be obtained by other monitoring adjuncts in the standard ICU setting.
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Affiliation(s)
- Himanshu Sharma
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States,*Correspondence: Himanshu Sharma ✉
| | - John P. McGinnis
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | | | - Shankar P. Gopinath
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Jerry C. Goodman
- Department of Pathology, Baylor College of Medicine, Houston, TX, United States
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Jovany Cruz Navarro
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States,Department of Anesthesiology, Baylor College of Medicine, Houston, TX, United States
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18
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Brain Tissue Oxygen Levels as a Perspective Therapeutic Target in Traumatic Brain Injury. Retrospective Cohort Study. J Crit Care Med (Targu Mures) 2023; 9:12-19. [PMID: 36890978 PMCID: PMC9987269 DOI: 10.2478/jccm-2023-0001] [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: 05/23/2022] [Accepted: 11/30/2022] [Indexed: 02/10/2023] Open
Abstract
Introduction Management of traumatic brain injury (TBI) requires a multidisciplinary approach and represents a significant challenge for both neurosurgeons and intensivists. The role of brain tissue oxygenation (PbtO2) monitoring and its impact on posttraumatic outcomes remains a controversial topic. Aim of the study Our study aimed to evaluate the impact of PbtO2 monitoring on mortality, 30 days and 6 months neurological outcomes in patients with severe TBI compared with those resulting from standard intracranial pressure (ICP) monitoring. Material and methods In this retrospective cohort study, we analysed the outcomes of 77 patients with severe TBI who met the inclusion criteria. These patients were divided into two groups, including 37 patients who were managed with ICP and PbtO2 monitoring protocols and 40 patients who were managed using ICP protocols alone. Results There were no significant differences in demographic data between the two groups. We found no statistically significant differences in mortality or Glasgow Outcome Scale (GOS) scores one month after TBI. However, our results revealed that GOS scores at 6 months had improved significantly among patients managed with PbtO2; this finding was particularly notable for Glasgow Outcome Scale (GOS) scores of 4-5. Close monitoring and management of reductions in PbtO2, particularly by increasing the fraction of inspired oxygen, was associated with higher partial pressures of oxygen in this group. Conclusions Monitoring of PbtO2 may facilitate the appropriate evaluation and treatment of low PbtO2 and represents a promising tool for the management of patients with severe TBI. Additional studies will be needed to confirm these findings.
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Intracranial-Pressure-Monitoring-Assisted Management Associated with Favorable Outcomes in Moderate Traumatic Brain Injury Patients with a GCS of 9-11. J Clin Med 2022; 11:jcm11226661. [PMID: 36431137 PMCID: PMC9694446 DOI: 10.3390/jcm11226661] [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: 10/10/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective: With a mortality rate of 10−30%, a moderate traumatic brain injury (mTBI) is one of the most variable traumas. The indications for intracranial pressure (ICP) monitoring in patients with mTBI and the effects of ICP on patients’ outcomes are uncertain. The purpose of this study was to examine the indications of ICP monitoring (ICPm) and its effects on the long-term functional outcomes of mTBI patients. Methods: Patients with Glasgow Coma Scale (GCS) scores of 9−11 at Tangdu hospital, between January 2015 and December 2021, were enrolled and treated in this retrospective cohort study. We assessed practice variations in ICP interventions using the therapy intensity level (TIL). Six-month mortality and a Glasgow Outcome Scale Extended (GOS-E) score were the main outcomes. The secondary outcome was neurological deterioration (ND) events. The indication and the estimated impact of ICPm on the functional outcome were investigated by using binary regression analyses. Results: Of the 350 patients, 145 underwent ICP monitoring-assisted management, and the other 205 patients received a standard control based on imaging or clinical examinations. A GCS ≤ 10 (OR 1.751 (95% CI 1.216−3.023), p = 0.003), midline shift (mm) ≥ 2.5 (OR 3.916 (95% CI 2.076−7.386) p < 0.001), and SDH (OR 1.772 (95% CI 1.065−2.949) p = 0.028) were predictors of ICP. Patients who had ICPm (14/145 (9.7%)) had a decreased 6-month mortality rate compared to those who were not monitored (40/205 (19.5%), p = 0.011). ICPm was linked to both improved neurological outcomes at 6 months (OR 0.815 (95% CI 0.712−0.933), p = 0.003) and a lower ND rate (2 = 11.375, p = 0.010). A higher mean ICP (17.32 ± 3.52, t = −6.047, p < 0.001) and a more significant number of ICP > 15 mmHg (27 (9−45.5), Z = −5.406, p < 0.001) or ICP > 20 mmHg (5 (0−23), Z = −4.635, p < 0.001) 72 h after injury were associated with unfavorable outcomes. The best unfavorable GOS-E cutoff value of different ICP characteristics showed that the mean ICP was >15.8 mmHg (AUC 0.698; 95% CI, 0.606−0.789, p < 0.001), the number of ICP > 15 mmHg was >25.5 (AUC 0.681; 95% CI, 0.587−0.774, p < 0.001), and the number of ICP > 20 mmHg was >6 (AUC 0.660; 95% CI, 0.561−0.759, p < 0.001). The total TIL score during the first 72 h post-injury in the non-ICP group (9 (8, 11)) was lower than that of the ICP group (13 (9, 17), Z = −8.388, p < 0.001), and was associated with unfavorable outcomes. Conclusion: ICPm-assisted management was associated with better clinical outcomes six months after discharge and lower incidences of ND for seven days post-injury. A mean ICP > 15.8 mmHg, the number of ICP > 15 mmHg > 25.5, or the number of ICP > 20 mmHg > 6 implicate an unfavorable long-term prognosis after 72 h of an mTBI.
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20
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 168] [Impact Index Per Article: 84.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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21
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Abstract
PURPOSE OF REVIEW Outcome following traumatic brain injury (TBI) remains variable, and derangements in cerebral metabolism are a common finding in patients with poor outcome. This review compares our understanding of cerebral metabolism in health with derangements seen following TBI. RECENT FINDINGS Ischemia is common within the first 24 h of injury and inconsistently detected by bedside monitoring. Metabolic derangements can also result from tissue hypoxia in the absence of ischemic reductions in blood flow due to microvascular ischemia and mitochondrial dysfunction. Glucose delivery across the injured brain is dependent on blood glucose and regional cerebral blood flow, and is an important contributor to derangements in glucose metabolism. Alternative energy substrates such as lactate, ketone bodies and succinate that may support mitochondrial function, and can be utilized when glucose availability is low, have been studied following TBI but require further investigation. SUMMARY Mitochondrial dysfunction and the use of alternative energy substrates are potential therapeutic targets, but improved understanding of the causes, impact and significance of metabolic derangements in clinical TBI are needed. Maintaining adequate oxygen and glucose delivery across the injured brain may accelerate the recovery of mitochondrial function and cerebral energy metabolism and remain important management targets.
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Affiliation(s)
- Simon Demers-Marcil
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
- Department of Anesthesiology and Critical Care, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Jonathan P. Coles
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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22
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Acharya D, Mukherjea A, Cao J, Ruesch A, Schmitt S, Yang J, Smith MA, Kainerstorfer JM. Non-Invasive Spectroscopy for Measuring Cerebral Tissue Oxygenation and Metabolism as a Function of Cerebral Perfusion Pressure. Metabolites 2022; 12:metabo12070667. [PMID: 35888791 PMCID: PMC9323243 DOI: 10.3390/metabo12070667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) and diffuse correlation spectroscopy (DCS) measure cerebral hemodynamics, which in turn can be used to assess the cerebral metabolic rate of oxygen (CMRO2) and cerebral autoregulation (CA). However, current mathematical models for CMRO2 estimation make assumptions that break down for cerebral perfusion pressure (CPP)-induced changes in CA. Here, we performed preclinical experiments with controlled changes in CPP while simultaneously measuring NIRS and DCS at rest. We observed changes in arterial oxygen saturation (~10%) and arterial blood volume (~50%) with CPP, two variables often assumed to be constant in CMRO2 estimations. Hence, we propose a general mathematical model that accounts for these variations when estimating CMRO2 and validate its use for CA monitoring on our experimental data. We observed significant changes in the various oxygenation parameters, including the coupling ratio (CMRO2/blood flow) between regions of autoregulation and dysregulation. Our work provides an appropriate model and preliminary experimental evidence for the use of NIRS- and DCS-based tissue oxygenation and metabolism metrics for non-invasive diagnosis of CA health in CPP-altering neuropathologies.
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Affiliation(s)
- Deepshikha Acharya
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Ankita Mukherjea
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Jiaming Cao
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Alexander Ruesch
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Samantha Schmitt
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Jason Yang
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Matthew A. Smith
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Jana M. Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
- Correspondence:
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23
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Brain Shock—Toward Pathophysiologic Phenotyping in Traumatic Brain Injury. Crit Care Explor 2022; 4:e0724. [PMID: 35815183 PMCID: PMC9257295 DOI: 10.1097/cce.0000000000000724] [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: 11/26/2022] Open
Abstract
Severe traumatic brain injury (TBI) is a heterogeneous pathophysiologic entity where multiple interacting mechanisms are operating. This viewpoint offers an emerging, clinically actionable understanding of the pathophysiologic heterogeneity and phenotypic diversity that comprise secondary brain injury based on multimodality neuromonitoring data. This pathophysiologic specification has direct implications for diagnostic, monitoring, and therapeutic planning. Cerebral shock can be helpfully subanalyzed into categories via an examination of the different types of brain tissue hypoxia and substrate failure: a) ischemic or flow dependent; b) flow-independent, which includes oxygen diffusion limitation, mitochondrial failure, and arteriovenous shunt; c) low extraction; and d) hypermetabolic. This approach could lead to an alternative treatment paradigm toward optimizing cerebral oxidative metabolism and energy crisis avoidance. Our bedside approach to TBI should respect the pathophysiologic diversity involved; operationalizing it in types of “brain shock” can be one such approach.
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24
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Management of moderate to severe traumatic brain injury: an update for the intensivist. Intensive Care Med 2022; 48:649-666. [PMID: 35595999 DOI: 10.1007/s00134-022-06702-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/09/2022] [Indexed: 01/04/2023]
Abstract
Traumatic brain injury (TBI) remains one of the most fatal and debilitating conditions in the world. Current clinical management in severe TBI patients is mainly concerned with reducing secondary insults and optimizing the balance between substrate delivery and consumption. Over the past decades, multimodality monitoring has become more widely available, and clinical management protocols have been published that recommend potential interventions to correct pathophysiological derangements. Even while evidence from randomized clinical trials is still lacking for many of the recommended interventions, these protocols and algorithms can be useful to define a clear standard of therapy where novel interventions can be added or be compared to. Over the past decade, more attention has been paid to holistic management, in which hemodynamic, respiratory, inflammatory or coagulation disturbances are detected and treated accordingly. Considerable variability with regards to the trajectories of recovery exists. Even while most of the recovery occurs in the first months after TBI, substantial changes may still occur in a later phase. Neuroprognostication is challenging in these patients, where a risk of self-fulfilling prophecies is a matter of concern. The present article provides a comprehensive and practical review of the current best practice in clinical management and long-term outcomes of moderate to severe TBI in adult patients admitted to the intensive care unit.
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25
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Huang HK, Liu CY, Tzeng IS, Hsieh TH, Chang CY, Hou YT, Lin PC, Chen YL, Chien DS, Yiang GT, Wu MY. The association between blood pressure and in-hospital mortality in traumatic brain injury: Evidence from a 10-year analysis in a single-center. Am J Emerg Med 2022; 58:265-274. [PMID: 35752084 DOI: 10.1016/j.ajem.2022.05.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/28/2022] Open
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26
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Xu M, Li L, Liu H, Lu W, Ling X, Gong M. Rutaecarpine Attenuates Oxidative Stress-Induced Traumatic Brain Injury and Reduces Secondary Injury via the PGK1/KEAP1/NFR2 Signaling Pathway. Front Pharmacol 2022; 13:807125. [PMID: 35529443 PMCID: PMC9070303 DOI: 10.3389/fphar.2022.807125] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/22/2022] [Indexed: 01/17/2023] Open
Abstract
The oxidative stress response caused by traumatic brain injury (TBI) leads to secondary damage in the form of tissue damage and cell death. Nuclear transcription-related factor 2 (NRF2) is a key factor in the body against oxidative stress and has an important role in combating oxidative damage in TBI neurons. In the present study, we investigated whether rutaecarpine could activate the PGK1/KEAP1/NRF2 pathway to antagonize oxidative damage in TBI neurons. We performed controlled cortical impact (CCI) surgery on mice and taken H2O2 treatment on PC12 cells to construct TBI models. The results of western blot showed that the expression of PGK1, KEAP and NRF2 was regulated and accompanied by altered levels of oxidative stress, and the use of rutaecarpine in the TBI model mice significantly improved cognitive dysfunction, increased antioxidant capacity and reduced apoptosis in brain tissue. Similar antioxidant damage results were obtained using rutaecarpine in a PC12 cell model. Furthermore, through the use of the protein synthesis inhibitor CHX and the proteasome synthesis inhibitor MG-132, rutaecarpine was found to promote the expreesions of PGK1 and NRF2 by accelerating PGK1 ubiquitination to reduce PGK1 expression. Therefore, rutaecarpine may be a promising therapeutic agent for the treatment of TBI-related neuro-oxidative damage.
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Affiliation(s)
- Min Xu
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, China
| | - Liu Li
- Collaborative Innovation Center of Jiangsu Province of Cancer Prevention and Treatment of Chinese Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Hua Liu
- Department of Neurosurgery, Affiliated Kunshan Hospital of Jiangsu University, Kunshan, China
| | - Wei Lu
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, China
| | - Xiaoyang Ling
- Department of Neurosurgery, Kunshan Hospital of Traditional Chinese Medicine, Kunshan Affiliated Hospital of Nanjing University of Chinese Medicine, Kunshan, China
| | - Mingjie Gong
- Department of Neurosurgery, Changshu No.2 People’s Hospital, The Affiliated Changshu Hospital of Xuzhou Medical University, Changshu, China
- *Correspondence: Mingjie Gong,
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27
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Foreman B, Lee H, Okonkwo DO, Strong AJ, Pahl C, Shutter LA, Dreier JP, Ngwenya LB, Hartings JA. The Relationship Between Seizures and Spreading Depolarizations in Patients with Severe Traumatic Brain Injury. Neurocrit Care 2022; 37:31-48. [PMID: 35174446 DOI: 10.1007/s12028-022-01441-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 01/04/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Both seizures and spreading depolarizations (SDs) are commonly detected using electrocorticography (ECoG) after severe traumatic brain injury (TBI). A close relationship between seizures and SDs has been described, but the implications of detecting either or both remain unclear. We sought to characterize the relationship between these two phenomena and their clinical significance. METHODS We performed a post hoc analysis of a prospective observational clinical study of patients with severe TBI requiring neurosurgery at five academic neurotrauma centers. A subdural electrode array was placed intraoperatively and ECoG was recorded during intensive care. SDs, seizures, and high-frequency background characteristics were quantified offline using published standards and terminology. The primary outcome was the Glasgow Outcome Scale-Extended score at 6 months post injury. RESULTS There were 138 patients with valid ECoG recordings; the mean age was 47 ± 19 years, and 104 (75%) were men. Overall, 2,219 ECoG-detected seizures occurred in 38 of 138 (28%) patients in a bimodal pattern, with peak incidences at 1.7-1.8 days and 3.8-4.0 days post injury. Seizures detected on scalp electroencephalography (EEG) were diagnosed by standard clinical care in only 18 of 138 (13%). Of 15 patients with ECoG-detected seizures and contemporaneous scalp EEG, seven (47%) had no definite scalp EEG correlate. ECoG-detected seizures were significantly associated with the severity and number of SDs, which occurred in 83 of 138 (60%) of patients. Temporal interactions were observed in 17 of 24 (70.8%) patients with both ECoG-detected seizures and SDs. After controlling for known prognostic covariates and the presence of SDs, seizures detected on either ECoG or scalp EEG did not have an independent association with 6-month functional outcome but portended worse outcome among those with clustered or isoelectric SDs. CONCLUSIONS In patients with severe TBI requiring neurosurgery, seizures were half as common as SDs. Seizures would have gone undetected without ECoG monitoring in 20% of patients. Although seizures alone did not influence 6-month functional outcomes in this cohort, they were independently associated with electrographic worsening and a lack of motor improvement following surgery. Temporal interactions between ECoG-detected seizures and SDs were common and held prognostic implications. Together, seizures and SDs may occur along a dynamic continuum of factors critical to the development of secondary brain injury. ECoG provides information integral to the clinical management of patients with TBI.
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Affiliation(s)
- Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA. .,Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, OH, USA.
| | - Hyunjo Lee
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA.,Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, OH, USA
| | - David O Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Anthony J Strong
- Department of Basic and Clinical Neuroscience, King's College London, London, UK
| | - Clemens Pahl
- Department of Intensive Care Medicine, King's College Hospital, London, UK
| | - Lori A Shutter
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Critical Care Medicine and Neurology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jens P Dreier
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Experimental Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Department of Neurology, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, and Berlin Institute of Health, Berlin, Germany.,Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany.,Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Laura B Ngwenya
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH, USA.,Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
| | - Jed A Hartings
- Collaborative for Research on Acute Neurological Injuries, University of Cincinnati, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati, Cincinnati, OH, USA
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28
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Wilde EA, Wanner I, Kenney K, Gill J, Stone JR, Disner S, Schnakers C, Meyer R, Prager EM, Haas M, Jeromin A. A Framework to Advance Biomarker Development in the Diagnosis, Outcome Prediction, and Treatment of Traumatic Brain Injury. J Neurotrauma 2022; 39:436-457. [PMID: 35057637 PMCID: PMC8978568 DOI: 10.1089/neu.2021.0099] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Elisabeth A. Wilde
- University of Utah, Neurology, 383 Colorow, Salt Lake City, Utah, United States, 84108
- VA Salt Lake City Health Care System, 20122, 500 Foothill Dr., Salt Lake City, Utah, United States, 84148-0002
| | - Ina Wanner
- UCLA, Semel Institute, NRB 260J, 635 Charles E. Young Drive South, Los Angeles, United States, 90095-7332, ,
| | - Kimbra Kenney
- Uniformed Services University of the Health Sciences, Neurology, Center for Neuroscience and Regenerative Medicine, 4301 Jones Bridge Road, Bethesda, Maryland, United States, 20814
| | - Jessica Gill
- National Institutes of Health, National Institute of Nursing Research, 1 cloister, Bethesda, Maryland, United States, 20892
| | - James R. Stone
- University of Virginia, Radiology and Medical Imaging, Box 801339, 480 Ray C. Hunt Dr. Rm. 185, Charlottesville, Virginia, United States, 22903, ,
| | - Seth Disner
- Minneapolis VA Health Care System, 20040, Minneapolis, Minnesota, United States
- University of Minnesota Medical School Twin Cities, 12269, 10Department of Psychiatry and Behavioral Sciences, Minneapolis, Minnesota, United States
| | - Caroline Schnakers
- Casa Colina Hospital and Centers for Healthcare, 6643, Pomona, California, United States
- Ronald Reagan UCLA Medical Center, 21767, Los Angeles, California, United States
| | - Restina Meyer
- Cohen Veterans Bioscience, 476204, New York, New York, United States
| | - Eric M Prager
- Cohen Veterans Bioscience, 476204, External Affairs, 535 8th Ave, New York, New York, United States, 10018
| | - Magali Haas
- Cohen Veterans Bioscience, 476204, 535 8th Avenue, 12th Floor, New York City, New York, United States, 10018,
| | - Andreas Jeromin
- Cohen Veterans Bioscience, 476204, Translational Sciences, Cambridge, Massachusetts, United States
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29
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Hermanides J, Hong YT, Trivedi M, Outtrim J, Aigbirhio F, Nestor PJ, Guilfoyle M, Winzeck S, Newcombe VFJ, Das T, Correia MM, Carpenter KLH, Hutchinson PJA, Gupta AK, Fryer TD, Pickard JD, Menon DK, Coles JP. Metabolic derangements are associated with impaired glucose delivery following traumatic brain injury. Brain 2021; 144:3492-3504. [PMID: 34240124 PMCID: PMC8677561 DOI: 10.1093/brain/awab255] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 05/20/2021] [Accepted: 06/14/2021] [Indexed: 11/13/2022] Open
Abstract
Metabolic derangements following traumatic brain injury are poorly characterized. In this single-centre observational cohort study we combined 18F-FDG and multi-tracer oxygen-15 PET to comprehensively characterize the extent and spatial pattern of metabolic derangements. Twenty-six patients requiring sedation and ventilation with intracranial pressure monitoring following head injury within a Neurosciences Critical Care Unit, and 47 healthy volunteers were recruited. Eighteen volunteers were excluded for age over 60 years (n = 11), movement-related artefact (n = 3) or physiological instability during imaging (n = 4). We measured cerebral blood flow, blood volume, oxygen extraction fraction, and 18F-FDG transport into the brain (K1) and its phosphorylation (k3). We calculated oxygen metabolism, 18F-FDG influx rate constant (Ki), glucose metabolism and the oxygen/glucose metabolic ratio. Lesion core, penumbra and peri-penumbra, and normal-appearing brain, ischaemic brain volume and k3 hotspot regions were compared with plasma and microdialysis glucose in patients. Twenty-six head injury patients, median age 40 years (22 male, four female) underwent 34 combined 18F-FDG and oxygen-15 PET at early, intermediate, and late time points (within 24 h, Days 2-5, and Days 6-12 post-injury; n = 12, 8, and 14, respectively), and were compared with 20 volunteers, median age 43 years (15 male, five female) who underwent oxygen-15, and nine volunteers, median age 56 years (three male, six female) who underwent 18F-FDG PET. Higher plasma glucose was associated with higher microdialysate glucose. Blood flow and K1 were decreased in the vicinity of lesions, and closely related when blood flow was <25 ml/100 ml/min. Within normal-appearing brain, K1 was maintained despite lower blood flow than volunteers. Glucose utilization was globally reduced in comparison with volunteers (P < 0.001). k3 was variable; highest within lesions with some patients showing increases with blood flow <25 ml/100 ml/min, but falling steeply with blood flow lower than 12 ml/100 ml/min. k3 hotspots were found distant from lesions, with k3 increases associated with lower plasma glucose (Rho -0.33, P < 0.001) and microdialysis glucose (Rho -0.73, P = 0.02). k3 hotspots showed similar K1 and glucose metabolism to volunteers despite lower blood flow and oxygen metabolism (P < 0.001, both comparisons); oxygen extraction fraction increases consistent with ischaemia were uncommon. We show that glucose delivery was dependent on plasma glucose and cerebral blood flow. Overall glucose utilization was low, but regional increases were associated with reductions in glucose availability, blood flow and oxygen metabolism in the absence of ischaemia. Clinical management should optimize blood flow and glucose delivery and could explore the use of alternative energy substrates.
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Affiliation(s)
- Jeroen Hermanides
- University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Young T Hong
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Monica Trivedi
- University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Joanne Outtrim
- University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Franklin Aigbirhio
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter J Nestor
- Queensland Brain Institute, University of Queensland, Brisbane, Australia
| | - Matthew Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan Winzeck
- University Division of Anaesthesia, University of Cambridge, Cambridge, UK
- BioMedIA Group, Department of Computing, Imperial College, London, UK
| | | | - Tilak Das
- Department of Radiology, Addenbrooke’s Hospital, Cambridge, UK
| | - Marta M Correia
- MRC Cognition and Brain Sciences Unit, University of Cambridge, Cambridge, UK
| | - Keri L H Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter J A Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Arun K Gupta
- University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Tim D Fryer
- Wolfson Brain Imaging Centre, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - John D Pickard
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - David K Menon
- University Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Jonathan P Coles
- University Division of Anaesthesia, University of Cambridge, Cambridge, UK
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30
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Turtzo LC, Luby M, Jikaria N, Griffin AD, Greenman D, Bokkers RPH, Parikh G, Peterkin N, Whiting M, Latour LL. Cytotoxic Edema Associated with Hemorrhage Predicts Poor Outcome after Traumatic Brain Injury. J Neurotrauma 2021; 38:3107-3118. [PMID: 34541886 DOI: 10.1089/neu.2021.0037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Magnetic resonance imaging (MRI) is used rarely in the acute evaluation of traumatic brain injury (TBI) but may identify findings of clinical importance not detected by computed tomography (CT). We aimed to characterize the association of cytotoxic edema and hemorrhage, including traumatic microbleeds, on MRI obtained within hours of acute head trauma and investigated the relationship to clinical outcomes. Patients prospectively enrolled in the Traumatic Head Injury Neuroimaging Classification study (NCT01132937) with evidence of diffusion-related findings or hemorrhage on neuroimaging were included. Blinded interpretation of MRI for diffusion-weighted lesions and hemorrhage was conducted, with subsequent quantification of apparent diffusion coefficient (ADC) values. Of 161 who met criteria, 82 patients had conspicuous hyperintense lesions on diffusion-weighted imaging (DWI) with corresponding regions of hypointense ADC in proximity to hemorrhage. Median time from injury to MRI was 21 (10-30) h. Median ADC values per patient grouped by time from injury to MRI were lowest within 24 h after injury. The ADC values associated with hemorrhagic lesions are lowest early after injury, with an increase in diffusion during the subacute period, suggesting transformation from cytotoxic to vasogenic edema during the subacute post-injury period. Of 118 patients with outcome data, 60 had Glasgow Outcome Scale Extended scores ≤6 at 30/90 days post-injury. Cytotoxic edema on MRI (odds ratio [OR] 2.91 [1.32-6.37], p = 0.008) and TBI severity (OR 2.51 [1.32-4.74], p = 0.005) were independent predictors of outcome. These findings suggest that in patients with TBI who had findings of hemorrhage on CT, patients with DWI/ADC lesions on MRI are more likely to do worse.
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Affiliation(s)
- L Christine Turtzo
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Marie Luby
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Neekita Jikaria
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
| | | | - Danielle Greenman
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Gunjan Parikh
- R Adams Shock Trauma Center and University of Maryland School of Medicine, Baltimore, Maryland, USA.,Division of Neurocritical Care and Emergency Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Nicole Peterkin
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
| | - Mark Whiting
- Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
| | - Lawrence L Latour
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA.,Center for Neuroscience and Regenerative Medicine, Bethesda, Maryland, USA
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31
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Zeiler FA, Iturria-Medina Y, Thelin EP, Gomez A, Shankar JJ, Ko JH, Figley CR, Wright GEB, Anderson CM. Integrative Neuroinformatics for Precision Prognostication and Personalized Therapeutics in Moderate and Severe Traumatic Brain Injury. Front Neurol 2021; 12:729184. [PMID: 34557154 PMCID: PMC8452858 DOI: 10.3389/fneur.2021.729184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 01/13/2023] Open
Abstract
Despite changes in guideline-based management of moderate/severe traumatic brain injury (TBI) over the preceding decades, little impact on mortality and morbidity have been seen. This argues against the “one-treatment fits all” approach to such management strategies. With this, some preliminary advances in the area of personalized medicine in TBI care have displayed promising results. However, to continue transitioning toward individually-tailored care, we require integration of complex “-omics” data sets. The past few decades have seen dramatic increases in the volume of complex multi-modal data in moderate and severe TBI care. Such data includes serial high-fidelity multi-modal characterization of the cerebral physiome, serum/cerebrospinal fluid proteomics, admission genetic profiles, and serial advanced neuroimaging modalities. Integrating these complex and serially obtained data sets, with patient baseline demographics, treatment information and clinical outcomes over time, can be a daunting task for the treating clinician. Within this review, we highlight the current status of such multi-modal omics data sets in moderate/severe TBI, current limitations to the utilization of such data, and a potential path forward through employing integrative neuroinformatic approaches, which are applied in other neuropathologies. Such advances are positioned to facilitate the transition to precision prognostication and inform a top-down approach to the development of personalized therapeutics in moderate/severe TBI.
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Affiliation(s)
- Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Centre on Aging, University of Manitoba, Winnipeg, MB, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Yasser Iturria-Medina
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada.,McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, QC, Canada.,Ludmer Centre for Neuroinformatics and Mental Health, Montreal, QC, Canada
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jai J Shankar
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ji Hyun Ko
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
| | - Chase R Figley
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
| | - Galen E B Wright
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Chris M Anderson
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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Xu L, Ware JB, Kim JJ, Shahim P, Silverman E, Magdamo B, Dabrowski C, Wesley L, Le MD, Morrison J, Zamore H, Lynch CE, Petrov D, Chen HI, Schuster J, Diaz-Arrastia R, Sandsmark DK. Arterial Spin Labeling Reveals Elevated Cerebral Blood Flow with Distinct Clusters of Hypo- and Hyperperfusion after Traumatic Brain Injury. J Neurotrauma 2021; 38:2538-2548. [PMID: 34115539 PMCID: PMC8403182 DOI: 10.1089/neu.2020.7553] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Imaging detection of brain perfusion alterations after traumatic brain injury (TBI) may provide prognostic insights. In this study, we used arterial spin labeling (ASL) to quantify cross-sectional and longitudinal changes in cerebral blood flow (CBF) after TBI and correlated changes with clinical outcome. We analyzed magnetic resonance imaging scans from adult participants with TBI requiring hospitalization in the acute (2 weeks post-injury, n = 33) and chronic (6 months post-injury, n = 16) phases, with 13 participants scanned longitudinally at both time points. We also analyzed 18 age- and sex-matched healthy controls. Whole-brain CBF maps were derived using a three-dimensional pseudo-continuous arterial spin label technique. Mean CBF across tissue-based regions (whole brain, gray matter, and white matter) was compared cross-sectionally and longitudinally. In addition, individual-level clusters of abnormal perfusion were identified using voxel-based z-score analysis of relative CBF maps, and number and volume of abnormally hypo- and hyperperfused clusters were assessed cross-sectionally and longitudinally. Finally, all CBF measures were correlated with clinical outcome measures. Mean global and gray matter CBF were significantly elevated in acute and chronic TBI participants compared to controls. Participants with better outcome at 6 months post-injury tended to have higher CBF in the acute phase compared to those with poorer outcome. Acute TBI participants had a significantly greater volume of hypo- and hyperperfused brain tissue compared to controls, with these regions partially normalizing by the chronic phase. Our findings demonstrate global elevation of CBF with focal hypo- and hyperperfusion in the early post-injury period and suggest a reparative role for acute elevation in CBF post-TBI.
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Affiliation(s)
- Linda Xu
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jeffrey B. Ware
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Junghoon J. Kim
- CUNY School of Medicine, The City College of New York, New York, New York, USA
| | | | - Erika Silverman
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Brigid Magdamo
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cian Dabrowski
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Leroy Wesley
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - My Duyen Le
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Justin Morrison
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Hannah Zamore
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Cillian E. Lynch
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Dmitriy Petrov
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - H. Isaac Chen
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - James Schuster
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Danielle K. Sandsmark
- The University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Lotze FP, Riess ML. Poloxamer 188 Exerts Direct Protective Effects on Mouse Brain Microvascular Endothelial Cells in an In Vitro Traumatic Brain Injury Model. Biomedicines 2021; 9:1043. [PMID: 34440247 PMCID: PMC8393826 DOI: 10.3390/biomedicines9081043] [Citation(s) in RCA: 3] [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: 06/23/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 12/04/2022] Open
Abstract
Traumatic Brain Injury (TBI), the main contributor to morbidity and mortality worldwide, can disrupt the cell membrane integrity of the vascular endothelial system, endangering blood-brain barrier function and threatening cellular subsistence. Protection of the vascular endothelial system might enhance clinical outcomes after TBI. Poloxamer 188 (P188) has been shown to improve neuronal function after ischemia/reperfusion (I/R) injury as well as after TBI. We aimed to establish an in vitro compression-type TBI model, comparing mild-to-moderate and severe injury, to observe the direct effects of P188 on Mouse Brain Microvascular Endothelial Cells (MBEC). Confluent MBEC were exposed to normoxic or hypoxic conditions for either 5 or 15 h (hours). 1 h compression was added, and P188 was administered during 2 h reoxygenation. A direct effect of P188 on MBEC was tested by assessing cell number/viability, cytotoxicity/membrane damage, metabolic activity, and total nitric oxide production (tNOp). While P188 enhanced cell number/viability, metabolic activity, and tNOp, an increase in cytotoxicity/membrane damage after mild-to-moderate injury was prevented. In severely injured MBEC, P188 improved metabolic activity only. P188, present during reoxygenation, influenced MBEC function directly in simulated I/R and compression-type TBI.
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Affiliation(s)
- Felicia P. Lotze
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
- Department of Anesthesiology, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Matthias L. Riess
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN 37232, USA;
- Department of Pharmacology, Vanderbilt University, Nashville, TN 37232, USA
- Anesthesiology, TVHS VA Medical Center, Nashville, TN 37212, USA
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Brain Temperature Influences Intracranial Pressure and Cerebral Perfusion Pressure After Traumatic Brain Injury: A CENTER-TBI Study. Neurocrit Care 2021; 35:651-661. [PMID: 34331210 PMCID: PMC8692292 DOI: 10.1007/s12028-021-01294-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 06/09/2021] [Indexed: 11/05/2022]
Abstract
Background After traumatic brain injury (TBI), fever is frequent. Brain temperature (BT), which is directly linked to body temperature, may influence brain physiology. Increased body and/or BT may cause secondary brain damage, with deleterious effects on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and outcome. Methods Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI), a prospective multicenter longitudinal study on TBI in Europe and Israel, includes a high resolution cohort of patients with data sampled at a high frequency (from 100 to 500 Hz). In this study, simultaneous BT, ICP, and CPP recordings were investigated. A mixed-effects linear model was used to examine the association between different BT levels and ICP. We additionally focused on changes in ICP and CPP during the episodes of BT changes (Δ BT ≥ 0.5 °C lasting from 15 min to 3 h) up or downward. The significance of ICP and CPP variations was estimated with the paired samples Wilcoxon test (also known as Wilcoxon signed-rank test). Results Twenty-one patients with 2,435 h of simultaneous BT and ICP monitoring were studied. All patients reached a BT of 38 °C and experienced at least one episode of ICP above 20 mm Hg. The linear mixed-effects model revealed an association between BT above 37.5 °C and higher ICP levels that was not confirmed for lower BT. We identified 149 episodes of BT changes. During BT elevations (n = 79) ICP increased, whereas CPP was reduced; opposite ICP and CPP variations occurred during episodes of BT reduction (n = 70). All these changes were of moderate clinical relevance (increase of ICP of 4.5 and CPP decrease of 7.5 mm Hg for BT rise, and ICP reduction of 1.7 and CPP elevation of 3.7 mm Hg during BT defervescence), even if statistically significant (p < 0.0001). It has to be noted, however, that a number of therapeutic interventions against intracranial hypertension was documented during those episodes. Conclusions Patients after TBI usually develop BT > 38 °C soon after the injury. BT may influence brain physiology, as reflected by ICP and CPP. An association between BT exceeding 37.5 °C and a higher ICP was identified but not confirmed for lower BT ranges. The relationship between BT, ICP, and CPP become clearer during rapid temperature changes. During episodes of temperature elevation, BT seems to have a significant impact on ICP and CPP.
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Mughal A, Sackheim AM, Sancho M, Longden TA, Russell S, Lockette W, Nelson MT, Freeman K. Impaired capillary-to-arteriolar electrical signaling after traumatic brain injury. J Cereb Blood Flow Metab 2021; 41:1313-1327. [PMID: 33050826 PMCID: PMC8142130 DOI: 10.1177/0271678x20962594] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/28/2020] [Accepted: 08/31/2020] [Indexed: 12/20/2022]
Abstract
Traumatic brain injury (TBI) acutely impairs dynamic regulation of local cerebral blood flow, but long-term (>72 h) effects on functional hyperemia are unknown. Functional hyperemia depends on capillary endothelial cell inward rectifier potassium channels (Kir2.1) responding to potassium (K+) released during neuronal activity to produce a regenerative, hyperpolarizing electrical signal that propagates from capillaries to dilate upstream penetrating arterioles. We hypothesized that TBI causes widespread disruption of electrical signaling from capillaries-to-arterioles through impairment of Kir2.1 channel function. We randomized mice to TBI or control groups and allowed them to recover for 4 to 7 days post-injury. We measured in vivo cerebral hemodynamics and arteriolar responses to local stimulation of capillaries with 10 mM K+ using multiphoton laser scanning microscopy through a cranial window under urethane and α-chloralose anesthesia. Capillary angio-architecture was not significantly affected following injury. However, K+-induced hyperemia was significantly impaired. Electrophysiology recordings in freshly isolated capillary endothelial cells revealed diminished Ba2+-sensitive Kir2.1 currents, consistent with a reduction in channel function. In pressurized cerebral arteries isolated from TBI mice, K+ failed to elicit the vasodilation seen in controls. We conclude that disruption of endothelial Kir2.1 channel function impairs capillary-to-arteriole electrical signaling, contributing to altered cerebral hemodynamics after TBI.
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Affiliation(s)
- Amreen Mughal
- Department of Pharmacology, University of Vermont, Burlington, VT, USA
| | | | - Maria Sancho
- Department of Pharmacology, University of Vermont, Burlington, VT, USA
| | - Thomas A Longden
- Department of Physiology, School of Medicine, University of Maryland, Baltimore, MD, USA
| | - Sheila Russell
- Department of Surgery, University of Vermont, Burlington, VT, USA
| | - Warren Lockette
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI, USA
| | - Mark T Nelson
- Department of Pharmacology, University of Vermont, Burlington, VT, USA
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Kalev Freeman
- Department of Pharmacology, University of Vermont, Burlington, VT, USA
- Department of Surgery, University of Vermont, Burlington, VT, USA
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Simeone P, Bruder N. NIRS, a gadget or a must for critically ill patients? Minerva Anestesiol 2021; 87:1171-1173. [PMID: 34036775 DOI: 10.23736/s0375-9393.21.15831-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Pierre Simeone
- AP-HM, Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France.,CNRS, Institut des Neurosciences de la Timone, UMR7289, Aix Marseille University, Marseille, France
| | - Nicolas Bruder
- AP-HM, Department of Anesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France -
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Nasution RA, Islam AA, Hatta M, Prihantono, Massi MN, Warsinggih, Kaelan C, Bahar B, Nasution KI, Wangi H, Faruk M. Effectiveness of CAPE in reducing vascular permeability after brain injury. MEDICINA CLÍNICA PRÁCTICA 2021; 4:100229. [DOI: 10.1016/j.mcpsp.2021.100229] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
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Feng B, Meng L, Luan L, Fang Z, Zhao P, Zhao G. Upregulation of Extracellular Vesicles-Encapsulated miR-132 Released From Mesenchymal Stem Cells Attenuates Ischemic Neuronal Injury by Inhibiting Smad2/c-jun Pathway via Acvr2b Suppression. Front Cell Dev Biol 2021; 8:568304. [PMID: 33763412 PMCID: PMC7982537 DOI: 10.3389/fcell.2020.568304] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 11/11/2020] [Indexed: 12/15/2022] Open
Abstract
Ischemic cerebrovascular disease is a significant and common public health issue worldwide. The emerging roles of mesenchymal stem cells (MSCs)-derived extracellular vesicles (EVs) in ischemic neuronal injury continue to be investigated. The current study aimed to investigate the role of EV-derived miR-132 from MSCs in ischemic neuronal injury. EVs were initially isolated from bone MSCs (BMSCs) and subsequently evaluated. A middle cerebral artery occlusion (MCAO) mouse model was constructed with the neurological function evaluated through a series of neurological scores, a pole test, and a foot fault test. Histopathological changes, neuron viability, and apoptosis, as well as cerebral infarction, were detected by hematoxylin and eosin (HE) staining and 2,3,5-triphenyltetrazolium hydrochloride (TTC) staining. The targeting relationship between microRNA (miR)-132 and Activin receptor type IIB (Acvr2b) was further confirmed based on dual-luciferase reporter gene assay results. Loss- and gain-of-function assays were conducted to elucidate the role of miR-132, EV-derived miR-132, Acvr2b, and Smad2 in oxygen-glucose deprivation (OGD)-treated neurons, and in mice models. Neuronal cell viability and apoptosis were evaluated via Cell Counting kit-8 (CCK-8) and flow cytometry. Our results indicated that Acvr2b was highly expressed, while miR-132 was poorly expressed in the MCAO mice and OGD-treated neurons. Acvr2b silencing or upregulation of miR-132 led to an elevation in neuronal activity, decreased neuronal apoptosis, reduced expression of Bax, and cleaved-caspase 3, as well as increased Bcl-2 expression. Acvr2b expression was targeted and inhibited by miR-132. EV-derived Acvr2b promoted activation of phosphorylated-Smad2 (p-Smad2)/c-jun signaling pathway, ultimately inducing neuronal injury. Our study provides evidence demonstrating that the overexpression of c-jun inhibits the protective role of MSCs-derived EV-miR-132 in neuronal injury. Upregulation of EV-derived miR-132 released from MSCs attenuates ischemic neuronal injury by inhibiting Smad2/c-jun pathways via the suppression of Acvr2b.
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Affiliation(s)
- Bin Feng
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Lei Meng
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Liming Luan
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhihao Fang
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Peng Zhao
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Guangyu Zhao
- Department of Neurosurgery, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
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Challenges and Opportunities in Multimodal Monitoring and Data Analytics in Traumatic Brain Injury. Curr Neurol Neurosci Rep 2021; 21:6. [PMID: 33527217 PMCID: PMC7850903 DOI: 10.1007/s11910-021-01098-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/13/2021] [Indexed: 10/25/2022]
Abstract
PURPOSE OF REVIEW Increasingly sophisticated systems for monitoring the brain have led to an increase in the use of multimodality monitoring (MMM) to detect secondary brain injuries before irreversible damage occurs after brain trauma. This review examines the challenges and opportunities associated with MMM in this population. RECENT FINDINGS Locally and internationally, the use of MMM varies. Practical challenges include difficulties with data acquisition, curation, and harmonization with other data sources limiting collaboration. However, efforts toward integration of MMM data, advancements in data science, and the availability of cloud-based infrastructures are now affording the opportunity for MMM to advance the care of patients with brain trauma. MMM provides data to guide the precision management of patients with traumatic brain injury in real time. While challenges exist, there are exciting opportunities for MMM to live up to this promise and to drive new insights into the physiology of the brain and beyond.
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Zhou Y, Fan R, Botchway BOA, Zhang Y, Liu X. Infliximab Can Improve Traumatic Brain Injury by Suppressing the Tumor Necrosis Factor Alpha Pathway. Mol Neurobiol 2021; 58:2803-2811. [PMID: 33501626 DOI: 10.1007/s12035-021-02293-1] [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] [Received: 09/30/2020] [Accepted: 01/12/2021] [Indexed: 12/14/2022]
Abstract
Traumatic brain injury (TBI) has both high morbidity and mortality rates and can negatively influence physical and mental health, while also causing extreme burden to both individual and society. Hitherto, there is no effective treatment for TBI because of the complexity of the brain anatomy and physiology. Currently, management strategies mainly focus on controlling inflammation after TBI. Tumor necrotizing factor alpha (TNF-α) plays a crucial role in neuroinflammation post-TBI. TNF-α acts as the initiator of downstream inflammatory signaling pathways, and its activation can trigger a series of inflammatory reactions. Infliximab is a monoclonal anti-TNF-α antibody that reduces inflammation. Herein, we review the latest findings pertaining to the role of TNF-α and infliximab in TBI. We seek to present a comprehensive clinical application prospect of infliximab in TBI and, thus, discuss potential strategies of infliximab in treating TBI.
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Affiliation(s)
- Yiru Zhou
- Department of Histology and Embryology, Medical College, Shaoxing City, China
| | - Ruihua Fan
- School of Life Science, Shaoxing University, Shaoxing City, China
| | - Benson O A Botchway
- Institute of Neuroscience, Zhejiang University School of Medicine, Hangzhou, China
| | - Yong Zhang
- Department of Histology and Embryology, Medical College, Shaoxing City, China
| | - Xuehong Liu
- Department of Histology and Embryology, Medical College, Shaoxing City, China.
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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: 3] [Impact Index Per Article: 0.8] [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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Price J, Sandbach DD, Ercole A, Wilson A, Barnard EBG. End-tidal and arterial carbon dioxide gradient in serious traumatic brain injury after prehospital emergency anaesthesia: a retrospective observational study. Emerg Med J 2020; 37:674-679. [PMID: 32928874 PMCID: PMC7588597 DOI: 10.1136/emermed-2019-209077] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 07/08/2020] [Accepted: 08/13/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES In the UK, 20% of patients with severe traumatic brain injury (TBI) receive prehospital emergency anaesthesia (PHEA). Current guidance recommends an end-tidal carbon dioxide (ETCO2) of 4.0-4.5 kPa (30.0-33.8 mm Hg) to achieve a low-normal arterial partial pressure of CO2 (PaCO2), and reduce secondary brain injury. This recommendation assumes a 0.5 kPa (3.8 mm Hg) ETCO2-PaCO2 gradient. However, the gradient in the acute phase of TBI is unknown. The primary aim was to report the ETCO2-PaCO2 gradient of TBI patients at hospital arrival. METHODS A retrospective cohort study of adult patients with serious TBI, who received a PHEA by a prehospital critical care team in the East of England between 1 April 2015 and 31 December 2017. Linear regression was performed to test for correlation and reported as R-squared (R2). A Bland-Altman plot was used to test for paired ETCO2 and PaCO2 agreement and reported with 95% CI. ETCO2-PaCO2 gradient data were compared with a two-tailed, unpaired, t-test. RESULTS 107 patients were eligible for inclusion. Sixty-seven patients did not receive a PaCO2 sample within 30 min of hospital arrival and were therefore excluded. Forty patients had complete data and were included in the final analysis; per protocol. The mean ETCO2-PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg), with moderate correlation (R2=0.23, p=0.002). The Bland-Altman bias was 1.7 (95% CI 1.4 to 2.0) kPa with upper and lower limits of agreement of 3.6 (95% CI 3.0 to 4.1) kPa and -0.2 (95% CI -0.8 to 0.3) kPa, respectively. There was no evidence of a larger gradient in more severe TBI (p=0.29). There was no significant gradient correlation in patients with a coexisting serious thoracic injury (R2=0.13, p=0.10), and this cohort had a larger ETCO2-PaCO2 gradient, 2.0 (±1.1) kPa (15.1 mm Hg), p=0.01. Patients who underwent prehospital arterial blood sampling had an arrival PaCO2 of 4.7 (±0.2) kPa (35.1 mm Hg). CONCLUSION There is only moderate correlation of ETCO2 and PaCO2 at hospital arrival in patients with serious TBI. The mean ETCO2-PaCO2 gradient was 1.7 (±1.0) kPa (12.8 mm Hg). Lower ETCO2 targets than previously recommended may be safe and appropriate, and there may be a role for prehospital PaCO2 measurement.
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Affiliation(s)
- James Price
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Addenbrooke's Hospital, Cambridge, UK
| | - Daniel D Sandbach
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Ari Ercole
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- University of Cambridge Division of Anaesthesia, Addenbrooke's Hospital, Cambridge, UK
| | - Alastair Wilson
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department (Retired), Royal London Hospital, London, UK
| | - Ed Benjamin Graham Barnard
- Department of Research, Audit, Innovation, & Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Addenbrooke's Hospital, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
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Lazaridis C, Goldenberg FD. Intracranial Pressure in Traumatic Brain Injury: From Thresholds to Heuristics. Crit Care Med 2020; 48:1210-1213. [PMID: 32697493 DOI: 10.1097/ccm.0000000000004383] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Department of Neurology, University of Chicago Medical Center, Chicago, IL
- Division of Neurocritical Care, Department of Surgery (Neurosurgery), University of Chicago Medical Center, Chicago, IL
| | - Fernando D Goldenberg
- Division of Neurocritical Care, Department of Neurology, University of Chicago Medical Center, Chicago, IL
- Division of Neurocritical Care, Department of Surgery (Neurosurgery), University of Chicago Medical Center, Chicago, IL
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Affiliation(s)
- Patrick M Kochanek
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA.
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA.
| | - Ruchira M Jha
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, Safar Center for Resuscitation Research, John G. Rangos Research Center, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 6th Floor, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, 4401 Penn Avenue, Pittsburgh, PA, USA
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Ichkova A, Rodriguez-Grande B, Zub E, Saudi A, Fournier ML, Aussudre J, Sicard P, Obenaus A, Marchi N, Badaut J. Early cerebrovascular and long-term neurological modifications ensue following juvenile mild traumatic brain injury in male mice. Neurobiol Dis 2020; 141:104952. [PMID: 32442681 DOI: 10.1016/j.nbd.2020.104952] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 05/05/2020] [Accepted: 05/17/2020] [Indexed: 12/15/2022] Open
Abstract
Clinical evidence suggests that a mild traumatic brain injury occurring at a juvenile age (jmTBI) may be sufficient to elicit pathophysiological modifications. However, clinical reports are not adequately integrated with experimental studies examining brain changes occurring post-jmTBI. We monitored the cerebrovascular modifications and assessed the long-term behavioral and electrographic changes resulting from experimental jmTBI. In vivo photoacoustic imaging demonstrated a decrease of cerebrovascular oxygen saturation levels in the impacted area hours post-jmTBI. Three days post-jmTBI oxygenation returned to pre-jmTBI levels, stabilizing at 7 and 30 days after the injury. At the functional level, cortical arterioles displayed no NMDA vasodilation response, while vasoconstriction induced by thromboxane receptor agonist was enhanced at 1 day post-jmTBI. Arterioles showed abnormal NMDA vasodilation at 3 days post-jmTBI, returning to normality at 7 days post injury. Histology showed changes in vessel diameters from 1 to 30 days post-jmTBI. Neurological evaluation indicated signs of anxiety-like behavior up to 30 days post-jmTBI. EEG recordings performed at the cortical site of impact 30 days post-jmTBI did not indicate seizures activity, although it revealed a reduction of gamma waves as compared to age matched sham. Histology showed decrease of neuronal filament staining. In conclusion, experimental jmTBI triggers an early cerebrovascular hypo‑oxygenation in vivo and faulty vascular reactivity. The exact topographical coherence and the direct casualty between early cerebrovascular changes and the observed long-term neurological modifications remain to be investigated. A potential translational value for cerebro-vascular oxygen monitoring in jmTBI is discussed.
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Affiliation(s)
| | | | - Emma Zub
- Cerebrovascular and Glia Research Laboratory, Department of Neuroscience, Institute of Functional Genomics (UMR 5203 CNRS-U1191 INSERM, University of Montpellier), Montpellier, France
| | - Amel Saudi
- Cerebrovascular and Glia Research Laboratory, Department of Neuroscience, Institute of Functional Genomics (UMR 5203 CNRS-U1191 INSERM, University of Montpellier), Montpellier, France
| | | | | | - Pierre Sicard
- INSERM, CNRS, Université de Montpellier, PhyMedExp, IPAM, Montpellier, France
| | - André Obenaus
- CNRS UMR5287, University of Bordeaux, Bordeaux, France; Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, CA, USA; Basic Science Department, Loma Linda University School of Medicine, Loma Linda, CA, USA; Center for Glial-Neuronal Interactions, Division of Biomedical Sciences, UC Riverside, Riverside, CA, USA; Department of Pediatrics, University of California, Irvine, Irvine, CA, USA
| | - Nicola Marchi
- Cerebrovascular and Glia Research Laboratory, Department of Neuroscience, Institute of Functional Genomics (UMR 5203 CNRS-U1191 INSERM, University of Montpellier), Montpellier, France.
| | - Jerome Badaut
- CNRS UMR5287, University of Bordeaux, Bordeaux, France; Basic Science Department, Loma Linda University School of Medicine, Loma Linda, CA, USA.
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Lalou AD, Levrini V, Czosnyka M, Gergelé L, Garnett M, Kolias A, Hutchinson PJ, Czosnyka Z. Cerebrospinal fluid dynamics in non-acute post-traumatic ventriculomegaly. Fluids Barriers CNS 2020; 17:24. [PMID: 32228689 PMCID: PMC7106631 DOI: 10.1186/s12987-020-00184-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 03/06/2020] [Indexed: 12/11/2022] Open
Abstract
Background Post-traumatic hydrocephalus (PTH) is potentially under-diagnosed and under-treated, generating the need for a more efficient diagnostic tool. We aim to report CSF dynamics of patients with post-traumatic ventriculomegaly. Materials and methods We retrospectively analysed post-traumatic brain injury (TBI) patients with ventriculomegaly who had undergone a CSF infusion test. We calculated the resistance to CSF outflow (Rout), AMP (pulse amplitude of intracranial pressure, ICP), dAMP (AMPplateau-AMPbaseline) and compensatory reserve index correlation coefficient between ICP and AMP (RAP). To avoid confounding factors, included patients had to be non-decompressed or with cranioplasty > 1 month previously and Rout > 6 mmHg/min/ml. Compliance was assessed using the elasticity coefficient. We also compared infusion-tested TBI patients selected for shunting versus those not selected for shunting (consultant decision based on clinical and radiological assessment and the infusion results). Finally, we used data from a group of shunted idiopathic Normal Pressure Hydrocephalus (iNPH) patients for comparison. Results Group A consisted of 36 patients with post-traumatic ventriculomegaly and Group B of 45 iNPH shunt responders. AMP and dAMP were significantly lower in Group A than B (0.55 ± 0.39 vs 1.02 ± 0.72; p < 0.01 and 1.58 ± 1.21 vs 2.76 ± 1.5; p < 0.01. RAP baseline was not significantly different between the two. Elasticity was higher than the normal limit in all groups (average 0.18 1/ml). Significantly higher Rout was present in those with probable PTH selected for shunting compared with unshunted. Mild/moderate hydrocephalus, ex-vacuo ventriculomegaly/encephalomalacia were inconsistently reported in PTH patients. Conclusions Rout and AMP were significantly lower in PTH compared to iNPH and did not always reflect the degree of hydrocephalus or atrophy reported on CT/MRI. Compliance appears reduced in PTH.
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Affiliation(s)
- Afroditi D Lalou
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK.
| | - Virginia Levrini
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Laurent Gergelé
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK.,Department of Intensive Care, Hôpital privé de la Loire, Saint Etienne, France
| | - Matthew Garnett
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Zofia Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
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47
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Coccolini F, Coimbra R, Ordonez C, Kluger Y, Vega F, Moore EE, Biffl W, Peitzman A, Horer T, Abu-Zidan FM, Sartelli M, Fraga GP, Cicuttin E, Ansaloni L, Parra MW, Millán M, DeAngelis N, Inaba K, Velmahos G, Maier R, Khokha V, Sakakushev B, Augustin G, di Saverio S, Pikoulis E, Chirica M, Reva V, Leppaniemi A, Manchev V, Chiarugi M, Damaskos D, Weber D, Parry N, Demetrashvili Z, Civil I, Napolitano L, Corbella D, Catena F. Liver trauma: WSES 2020 guidelines. World J Emerg Surg 2020; 15:24. [PMID: 32228707 PMCID: PMC7106618 DOI: 10.1186/s13017-020-00302-7] [Citation(s) in RCA: 108] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/06/2020] [Indexed: 02/06/2023] Open
Abstract
Liver injuries represent one of the most frequent life-threatening injuries in trauma patients. In determining the optimal management strategy, the anatomic injury, the hemodynamic status, and the associated injuries should be taken into consideration. Liver trauma approach may require non-operative or operative management with the intent to restore the homeostasis and the normal physiology. The management of liver trauma should be multidisciplinary including trauma surgeons, interventional radiologists, and emergency and ICU physicians. The aim of this paper is to present the World Society of Emergency Surgery (WSES) liver trauma management guidelines.
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Affiliation(s)
- Federico Coccolini
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy.
| | - Raul Coimbra
- Riverside University Health System, CECORC Research Center, Loma Linda University, Loma Linda, USA
| | - Carlos Ordonez
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus Haifa, Haifa, Israel
| | - Felipe Vega
- Department of Surgery, Hospital Angeles Lomas, Huixquilucan, Mexico
| | | | - Walt Biffl
- Trauma Surgery Department, Scripps Memorial Hospital La Jolla, San Diego, CA, USA
| | - Andrew Peitzman
- Surgery Department, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tal Horer
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden.,Department of Surgery, Örebro University Hospital, Örebro University, Örebro, Sweden
| | - Fikri M Abu-Zidan
- Department of Surgery, College of Medicine and Health Sciences, UAE University, Al-Ain, United Arab Emirates
| | - Massimo Sartelli
- General and Emergency Surgery, Macerata Hospital, Macerata, Italy
| | - Gustavo P Fraga
- Trauma/Acute Care Surgery & Surgical Critical Care, University of Campinas, Campinas, Brazil
| | - Enrico Cicuttin
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | - Luca Ansaloni
- General, Emergency and Trauma Surgery Department, Bufalini Hospital, Cesena, Italy
| | - Michael W Parra
- Department of Trauma Critical Care, Broward General Level I Trauma Center, Fort Lauderdale, FL, USA
| | - Mauricio Millán
- Division of Trauma and Acute Care Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Nicola DeAngelis
- Unit of Digestive Surgery, HPB Surgery and Liver Transplant, Henri Mondor Hospital, Créteil, France
| | - Kenji Inaba
- General and Trauma Surgery, LAC+USC Medical Center, Los Angeles, CA, USA
| | - George Velmahos
- General and Emergency Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Ron Maier
- Department of Surgery, Harborview Medical Centre, Seattle, USA
| | - Vladimir Khokha
- General Surgery Department, Mozir City Hospital, Mozir, Belarus
| | - Boris Sakakushev
- General Surgery Department, Medical University, University Hospital St George, Plovdiv, Bulgaria
| | - Goran Augustin
- Department of Surgery, Zagreb University Hospital Centre and School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Salomone di Saverio
- General and Trauma Surgery Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Emanuil Pikoulis
- 3rd Department of Surgery, Attiko Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | - Mircea Chirica
- Chirurgie Digestive, CHUGA-CHU Grenoble Alpes, Grenoble, France
| | - Viktor Reva
- General and Emergency Surgery, Sergei Kirov Military Academy, Saint Petersburg, Russia
| | - Ari Leppaniemi
- General Surgery Department, Mehilati Hospital, Helsinki, Finland
| | - Vassil Manchev
- General and Trauma Surgery Department, Pietermaritzburg Hospital, Pietermaritzburg, South Africa
| | - Massimo Chiarugi
- General, Emergency and Trauma Surgery Department, Pisa University Hospital, Via Paradisia 1, 56100, Pisa, Italy
| | | | - Dieter Weber
- Department of General Surgery, Royal Perth Hospital, Perth, Australia
| | - Neil Parry
- General and Trauma Surgery Department, London Health Sciences Centre, Victoria Hospital, London, ON, Canada
| | | | - Ian Civil
- Trauma Surgery, Auckland University Hospital, Auckland, New Zealand
| | - Lena Napolitano
- Division of Acute Care Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Fausto Catena
- Emergency and Trauma Surgery, Maggiore Hospital, Parma, Italy
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48
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Intracranial Pressure Threshold Heuristics in Traumatic Brain Injury: One, None, Many! Neurocrit Care 2020; 32:672-676. [DOI: 10.1007/s12028-020-00940-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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