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Tang J, Tang J, Liao Y, Bai L, Luo T, Xu Y, Liu Z. An in vitro comparative study on clot lysis efficiency of urokinase and reteplase with the synergy of ultrasound needle. Heliyon 2024; 10:e26624. [PMID: 38463819 PMCID: PMC10920158 DOI: 10.1016/j.heliyon.2024.e26624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 02/16/2024] [Accepted: 02/16/2024] [Indexed: 03/12/2024] Open
Abstract
Objectives Ultrasound Needle, which is an improved ultrasonic horn device, has shown great potential for promoting the diffusion of thrombolytic drugs within clots and enhancing clot lysis efficiency. However, the clot lysis efficiency of different thrombolytic drugs with the synergy of Ultrasound Needle remains unknown. In this study, we aimed to compare the lysis efficiency of the non-fibrin-specific drug urokinase and fibrin-specific drug reteplase with the synergy of Ultrasound Needle. Materials and methods Twenty-five milliliters of human blood was incubated for 1.5 h to form in vitro clots and then received the corresponding treatment protocols: control group (normal saline), US group (10 min of Ultrasound Needle treatment), UK group (30000IU of urokinase), r-PA group (2 mg of reteplase), US + UK group, and US + r-PA group. After treatment, the morphological changes of the clots were analyzed by B-mode ultrasound imaging and hematoxylin and eosin (H&E) staining. Lysis efficiency was evaluated based on the relative end weight (final weight/initial weight). The fibrin density of the different groups after treatment was assessed by immunofluorescence staining. Results Morphological examination and relative end weight analysis showed that combination therapies induced a more thorough dissolution of clots compared with single therapies, and the US + r-PA group exhibited higher lysis efficiency than the US + UK group. In addition, immunofluorescence staining showed that the US + r-PA group had fewer remaining thrombus fibrins than the US + UK group after treatment. Conclusions The Ultrasound Needle can significantly improve the clot lysis efficiency of both fibrinolytic drugs, and fibrin-specific reteplase exhibited superior lysis efficiency over non-fibrin-specific urokinase with the synergy of the Ultrasound Needle.
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Affiliation(s)
| | | | - Yiyi Liao
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, PR China
| | - Luhua Bai
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, PR China
| | - Tingting Luo
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, PR China
| | - Yali Xu
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, PR China
| | - Zheng Liu
- Department of Ultrasound, Xinqiao Hospital, Army Medical University, Chongqing, PR China
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Evaluating the Outcome of an Unnecessary Request for CT Scan in Be'sat Hospital of Hamadan. Radiol Res Pract 2023; 2023:3709015. [PMID: 36874208 PMCID: PMC9977522 DOI: 10.1155/2023/3709015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 01/26/2023] [Accepted: 01/27/2023] [Indexed: 02/24/2023] Open
Abstract
Aim This study aimed to investigate the frequency of unnecessary tests requested in Be'sat Hospital in Hamadan. Materials and Methods This descriptive research was conducted in order to investigate the frequency of unnecessary requests for CT scan and radiography of patients referring to the imaging department of Be'sat Hospital in Hamadan in a 4- to 6-month period. Patient information, including gender, age, type of CT scan test, the reason for requesting the test, the expertise of the requesting physician, and the result of the radiologist's report on each test, was extracted and collected. Results A total of 1000 CT scans were evaluated. The mean age of these patients was about 36 years and most of them were men. The highest and lowest percentages of unnecessary cases were related to CT scans of the brain (42.3%) and facial bones (2.3%), respectively. The most and the least unnecessary CT scans based on the reason given for the request were related to multiple physical trauma (30.7%) and chronic kidney disease (1.5%), respectively. Conclusion In all tests, over 74% of the reports were unnecessary and less than 26% were necessary. Therefore, it is necessary to reduce unnecessary requests to reduce the radiation dose of patients. Also, the knowledge of doctors should be increased in the field of appropriate evaluation of CT scan tests based on clinical guidelines.
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Mishra R, Ucros HEV, Florez-Perdomo WA, Suarez JR, Moscote-Salazar LR, Rahman MM, Agrawal A. Predictive Value of Rotterdam Score and Marshall Score in Traumatic Brain Injury: A Contemporary Review. INDIAN JOURNAL OF NEUROTRAUMA 2021. [DOI: 10.1055/s-0041-1727404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
AbstractThis article conducts a contemporary comparative review of the medical literature to update and establish evidence as to which framework among Rotterdam and Marshall computed tomography (CT)-based scoring systems predicts traumatic brain injury (TBI) outcomes better. The scheme followed was following the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines for literature search. The search started on August 15, 2020 and ended on December 31, 2020. The combination terms used were Medical Subject Headings terms, combination keywords, and specific words used for describing various pathologies of TBI to identify the most relevant article in each database. PICO question to guide the search strategy was: “what is the use of Marshall (I) versus Rotterdam score (C) in TBI patients (P) for mortality risk stratification (O).” The review is based on 46 references which included a full review of 14 articles for adult TBI patients and 6 articles for pediatric TBI articles comparing Rotterdam and Marshall CT scores. The review includes 8,243 patients, of which 2,365 were pediatric and 5,878 were adult TBI patients. Marshall CT classification is not ordinal, is more descriptive, has better inter-rater reliability, and poor performance in a specific group of TBI patients requiring decompressive craniectomy. Rotterdam CT classification is ordinal, has better discriminatory power, and a better description of the dynamics of intracranial changes. The two scoring systems are complimentary. A combination of clinical parameters, severity, ischemic and hemodynamic parameters, and CT scoring system could predict the prognosis of TBI patients with significant accuracy. None of the classifications has good evidence for use in pediatric patients.
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Affiliation(s)
- Rakesh Mishra
- Department of Neurosurgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Harold Enrique Vasquez Ucros
- Department of Medicina General, Universidad del Sinú - Elias Bechara Zainúm de Cartagena, Cartagena, Colombia
- Jefe de Investigacion ENCEPHALOS en Consejo LatinoAmericano de Neurointensivismo-CLaNi, Cartagena, Colombia
| | - William Andres Florez-Perdomo
- Department of Medicina General, Universidad Surcolombiana, Medico Investigador Consejo Latinoamericano de Neurointensivismo - CLaNi, Clinica Sahagún IPS SA, Cordoba, Columbia
| | - José Rojas Suarez
- Department of Medicina Intensiva, Epidemiologia Clinica, Intensive Care Research (GRICIO), Universidad de Cartagena, Corporacion Universitaria Rafael Nuñez, Cartagena, Colombia
| | | | - Md. Moshiur Rahman
- Department of Neurosurgery, Holy Family Red Crescent Medical College, Dhaka, Bangladesh
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Sheng J, Yang J, Cai S, Zhuang D, Li T, Chen X, Wang G, Dai J, Ding F, Tian L, Zheng F, Tian F, Huang M, Li K, Chen W. Development and external validation of a novel multihematoma fuzzy sign on computed tomography for predicting traumatic intraparenchymal hematoma expansion. Sci Rep 2021; 11:2042. [PMID: 33479430 PMCID: PMC7819987 DOI: 10.1038/s41598-021-81685-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 01/11/2021] [Indexed: 02/05/2023] Open
Abstract
Acute traumatic intraparenchymal hematoma (tICH) expansion is a devastating neurological complication that is associated with poor outcome after cerebral contusion. This study aimed to develop and validate a novel noncontrast computed tomography (CT) (NCCT) multihematoma fuzzy sign to predict acute tICH expansion. In this multicenter, prospective cohort study, multihematoma fuzzy signs on baseline CT were found in 212 (43.89%) of total 482 patients. Patients with the multihematoma fuzzy sign had a higher frequency of tICH expansion than those without (90.79% (138) vs. 46.71% (71)). The presence of multihematoma fuzzy sign was associated with increased risk for acute tICH expansion in entire cohort (odds ratio [OR]: 16.15; 95% confidence interval (CI) 8.85-29.47; P < 0.001) and in the cohort after propensity-score matching (OR: 9.37; 95% CI 4.52-19.43; P < 0.001). Receiver operating characteristic analysis indicated a better discriminative ability of the presence of multihematoma fuzzy sign for acute tICH expansion (AUC = 0.79; 95% CI 0.76-0.83), as was also observed in an external validation cohort (AUC = 0.76; 95% CI 0.67-0.84). The novel NCCT marker of multihematoma fuzzy sign could be easily identified on baseline CT and is an easy-to-use predictive tool for tICH expansion in the early stage of cerebral contusion.
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Affiliation(s)
- Jiangtao Sheng
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Jinhua Yang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Shirong Cai
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Dongzhou Zhuang
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Tian Li
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Xiaoxuan Chen
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Gefei Wang
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Jianping Dai
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Faxiu Ding
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China
| | - Lu Tian
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Fengqing Zheng
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China
| | - Fei Tian
- Department of Neurosurgery, Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong, China
| | - Mindong Huang
- Department of Neurosurgery, Affiliated Jieyang Hospital of Sun Yat-Sen University, Jieyang, Guangdong, China
| | - Kangsheng Li
- Department of Microbiology and Immunology and Key Immunopathology Laboratory of Guangdong Province, Shantou University Medical College, 22 Xinling Road, Shantou, Guangdong, China.
| | - Weiqiang Chen
- Department of Neurosurgery, First Affiliated Hospital of Shantou University Medical College, 57 Changping Road, Shantou, Guangdong, China.
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Surgical Management of Trauma-Related Intracranial Hemorrhage-a Review. Curr Neurol Neurosci Rep 2020; 20:63. [PMID: 33136200 DOI: 10.1007/s11910-020-01080-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2020] [Indexed: 12/26/2022]
Abstract
PURPOSE OF REVIEW The surgical management of trauma-related intracranial hemorrhage is characterized by marked heterogeneity. Large prospective randomized trials have generally been prohibited by the ubiquity of concordant pathology, diversity of trauma systems, and paucity of clinical equipoise among providers. RECENT FINDINGS To date, the results of retrospective studies and surgeon preference have driven the indications, modality, extent, and timing of surgical intervention in the global neurosurgical community. With advances in our understanding of the pathophysiology of hemorrhagic TBI and the advent of novel surgical techniques, a reevaluation of surgical indication, timing, and approach is warranted. In this way, we can work to optimize surgical outcomes, achieving maximal functional recovery while minimizing surgical morbidity.
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Joseph B, Sadoun M, Aziz H, Tang A, Wynne JL, Pandit V, Kulvatunyou N, O'keeffe T, Friese RS, Rhee P. Repeat Head Computed Tomography in Anticoagulated Traumatic Brain Injury Patients: Still Warranted. Am Surg 2020. [DOI: 10.1177/000313481408000123] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Anticoagulation agents are proven risk factors for intracranial hemorrhage (ICH) in traumatic brain injury (TBI). The aim of our study is to describe the epidemiology of prehospital coumadin, aspirin, and Plavix (CAP) patients with ICH and evaluate the use of repeat head computed tomography (CT) in this group. We performed a retrospective study from our trauma registry. All patients with intracranial hemorrhage on initial CT with prehospital CAP therapy were included. Demographics, CT scan findings, number of repeat CT scans, progressive findings, and neuro-surgical intervention were abstracted. A comparison between prehospital CAP and no-CAP patients was done using χ2 and Mann-Whitney U test. A total of 1606 patients with blunt TBI charts were reviewed of whom 508 patients had intracranial bleeding on initial CT scan and 72 were on prehospital CAP therapy. CAP patients were older ( P < 0.001), had higher Injury Severity Score and head Abbreviated Injury Scores on admission ( P < 0.001), were more likely to present with an abnormal neurologic examination ( P = 0.004), and had higher hospital and intensive care unit lengths of stay ( P < 0.005). Eighty-four per cent of patients were on antiplatelet therapy and 27 per cent were on warfarin. The CAP patients have a threefold increase in the rate of worsening repeat head CT (26 vs 9%, P < 0.05). Prehospital CAP therapy is high risk for progression of bleeding on repeat head CT. Routine repeat head CT remains an important component in this patient population and can provide useful information.
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Affiliation(s)
- Bellal Joseph
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Moutamn Sadoun
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Hassan Aziz
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Andrew Tang
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Julie L. Wynne
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Viraj Pandit
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Narong Kulvatunyou
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Terence O'keeffe
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Randall S. Friese
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
| | - Peter Rhee
- From the Division of Trauma, Department of Surgery, University of Arizona, Tucson, Arizona
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7
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Carnevale JA, Segar DJ, Powers AY, Shah M, Doberstein C, Drapcho B, Morrison JF, Williams JR, Collins S, Monteiro K, Asaad WF. Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage. J Neurosurg 2019; 129:1305-1316. [PMID: 29303442 DOI: 10.3171/2017.7.jns17988] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 07/06/2017] [Indexed: 11/06/2022]
Abstract
Here, the authors examined the factors involved in the volumetric progression of traumatic brain contusions. The variables significant in this progression are identified, and the expansion rate of a brain bleed can now effectively be predicted given the presenting characteristics of the patient.
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Affiliation(s)
- Joseph A Carnevale
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David J Segar
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,2Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew Y Powers
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Meghal Shah
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Benjamin Drapcho
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John F Morrison
- 3Department of Neurosurgery, University at Buffalo, New York
| | - John R Williams
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,5Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | | | - Kristina Monteiro
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Wael F Asaad
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,7Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island
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8
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Bodanapally UK, Shanmuganathan K, Ramaswamy M, Tsymbalyuk S, Aarabi B, Parikh GY, Schwartzbauer G, Dreizin D, Simard JM, Ptak T, Li G, Liang Y, Fleiter TR. Iodine-based Dual-Energy CT of Traumatic Hemorrhagic Contusions: Relationship to In-Hospital Mortality and Short-term Outcome. Radiology 2019; 292:730-738. [PMID: 31361206 DOI: 10.1148/radiol.2019190078] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BackgroundTraumatic hemorrhagic contusions are associated with iodine leak; however, quantification of leakage and its importance to outcome is unclear.PurposeTo identify iodine-based dual-energy CT variables that correlate with in-hospital mortality and short-term outcomes for contusions at hospital discharge.Materials and MethodsIn this retrospective study, consecutive patients with contusions from May 2016 through January 2017 were analyzed. Two radiologists evaluated CT variables from unenhanced admission head CT and follow-up head dual-energy CT scans obtained after contrast material-enhanced whole-body CT. The outcomes evaluated were in-hospital mortality, Rancho Los Amigos scale (RLAS) score, and disability rating scale (DRS) score. Logistic regression and linear regression were used to develop prediction models for categorical and continuous outcomes, respectively.ResultsThe study included 65 patients (median age, 48 years; interquartile range, 25-65.5 years); 50 were men. Dual-energy CT variables that correlated with mortality, RLAS score, and DRS score were iodine concentration, pseudohematoma volume, iodine quantity in pseudohematoma, and iodine quantity in contusion. The single-energy CT variable that correlated with mortality, RLAS score, and DRS score was hematoma volume at follow-up CT. Multiple logistic regression analysis after inclusion of clinical variables identified two predictors that enabled determination of mortality: postresuscitation Glasgow coma scale (P-GCS) (adjusted odds ratio, 0.42; 95% confidence interval [CI]: 0.2, 0.86; P = 0.01) and iodine quantity in pseudohematoma (adjusted odds ratio, 1.4 per milligram; 95% CI: 1.02 per milligram, 1.9 per milligram; P = 0.03), with a mean area under the receiver operating characteristic curve of 0.96 ± 0.05 (standard error). For RLAS, the predictors were P-GCS (mean coefficient, 0.32 ± 0.06; P < .001) and iodine quantity in contusion (mean coefficient, -0.04 per milligram ± 0.02; P = 0.01). Predictors for DRS were P-GCS (mean coefficient, -1.15 ± 0.27; P < .001), age (mean coefficient, 0.13 per year ± 0.04; P = .002), and iodine quantity in contusion (mean coefficient, 0.19 per milligram ± 0.07; P = .02).ConclusionIodine-based dual-energy CT variables correlate with in-hospital mortality and short-term outcomes for contusions at hospital discharge.© RSNA, 2019Online supplemental material is available for this article.See also the editorial by Talbott and Hess in this issue.
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Affiliation(s)
- Uttam K Bodanapally
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Kathirkamanathan Shanmuganathan
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Meghna Ramaswamy
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Solomiya Tsymbalyuk
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Bizhan Aarabi
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Gunjan Y Parikh
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Gary Schwartzbauer
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - David Dreizin
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - J Marc Simard
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Thomas Ptak
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Guang Li
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Yuanyuan Liang
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
| | - Thorsten R Fleiter
- From the Departments of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., D.D., T.P., G.L., T.R.F.), Neurosurgery (B.A., G.S., M.S.), Neurology, R. Adams Cowley Shock Trauma Center (Y.G.P.), Epidemiology and Public Health (Y.L.), University of Maryland School of Medicine, 22 S Greene St, Baltimore, MD 21201; and University of Maryland School of Medicine, Baltimore, Md (M.R., S.T.)
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9
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Rezaii PG, Grant GA, Zeineh MM, Richardson KJ, Coburn ML, Bet AM, Weber A, Jiang B, Li Y, Ubungen K, Routh G, Wheatcroft AM, Paulino AD, Hayes RL, Steinberg GK, Wintermark M. Stability of Blood Biomarkers of Traumatic Brain Injury. J Neurotrauma 2019; 36:2407-2416. [PMID: 30968744 DOI: 10.1089/neu.2018.6053] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Blood biomarker tests were recently approved for clinical diagnosis of traumatic brain injury (TBI), yet there are still fundamental questions that need attention. One such question is the stability of putative biomarkers in blood over the course of several days after injury if the sample is unable to be processed into serum or plasma and stored at low temperatures. Blood may not be able to be stored at ultra-low temperatures in austere combat or sports environments. In this prospective study of 20 adult patients with positive head computed tomography imaging findings, the stability of three biomarkers (glial fibrillary acidic protein [GFAP], ubiquitin C-terminal hydrolase-L1 [UCH-L1], and S100 calcium binding protein B [S100B]) in whole blood and in serum stored at 4-5°C was evaluated over the course of 72 h after blood collection. The amount of time whole blood and serum were refrigerated had no significant effect on GFAP concentration in plasma obtained from whole blood and in serum (p = 0.6256 and p = 0.3687, respectively), UCH-L1 concentration in plasma obtained from whole blood and in serum (p = 0.0611 and p = 0.5189, respectively), and S100B concentration in serum (p = 0.4663). Concentration levels of GFAP, UCH-L1, and S100B in blood collected from patients with TBI were found to be stable at 4-5°C for at least 3 days after blood draw. This study suggests that the levels of the three diagnostic markers above are still valid for diagnostic TBI tests if the sample is stored in 4-5°C refrigerated conditions.
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Affiliation(s)
| | | | | | | | - Maria Lynn Coburn
- 2Department of Neurosurgery, Stanford University, Stanford, California
| | - Anthony Marco Bet
- 2Department of Neurosurgery, Stanford University, Stanford, California
| | - Art Weber
- 4Banyan Biomarkers Inc., San Diego, California
| | - Bin Jiang
- 1Department of Radiology, Stanford University, Stanford, California
| | - Ying Li
- 1Department of Radiology, Stanford University, Stanford, California
| | - Kristine Ubungen
- 3Department of Anatomic Pathology and Clinical Laboratories, Stanford University, Stanford, California
| | - Gay Routh
- 3Department of Anatomic Pathology and Clinical Laboratories, Stanford University, Stanford, California
| | | | | | | | | | - Max Wintermark
- 1Department of Radiology, Stanford University, Stanford, California
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Pandya U, Pattison J, Karas C, O'Mara M. Does the Presence of Subdural Hemorrhage Increase the Risk of Intracranial Hemorrhage Expansion after the Initiation of Antithrombotic Medication?. Am Surg 2018. [DOI: 10.1177/000313481808400327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Patients with traumatic intracranial hemorrhage (ICH) with a clinical indication for antithrombotic medication present a clinical dilemma, burdened by the task of weighing the risks of hemorrhage expansion against the risk of thrombosis. We sought to determine the effect of subdural hemorrhage on the risk of hemorrhage expansion after administration of antithrombotic medication. Medical records of 1626 trauma patients admitted with traumatic ICH between March 1, 2008, and March 31, 2013, to a Level I trauma center were retrospectively reviewed. The pharmacy database was queried to determine which patients were administered anticoagulant or antiplatelet medication during their hospitalization, leaving a sample of 97 patients that met inclusion criteria. Patients presenting with subdural hemorrhage were compared with patients without subdural hemorrhage. Demographic data, clinically significant expansion of hematoma, postinjury day of initiation, and mortality were analyzed. A total of 97 patients met inclusion criteria with 55 patients in the subdural hemorrhage group and 42 in the other ICH group. There were no significant differences in age, gender, injury severity score, admission Glasgow coma score, or mean hospital day of antithrombotic administration between the groups. Patients with subdural hemorrhage had a significantly higher rate of ICH expansion (9.1 vs 0%, P = 0.045). There was no difference in overall hospital mortality between the two groups. Incidence of ICH expansion was higher in patients with subdural hemorrhage. It may be prudent to use special caution when administering antiplatelet or anticoagulant medication in this group of patients after injury.
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Affiliation(s)
- Urmil Pandya
- Trauma Services, Grant Medical Center, Columbus, Ohio
| | - Jill Pattison
- Trauma Services, Grant Medical Center, Columbus, Ohio
| | - Chris Karas
- Trauma Services, Grant Medical Center, Columbus, Ohio
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Bodanapally UK, Shanmuganathan K, Issa G, Dreizin D, Li G, Sudini K, Fleiter TR. Dual-Energy CT in Hemorrhagic Progression of Cerebral Contusion: Overestimation of Hematoma Volumes on Standard 120-kV Images and Rectification with Virtual High-Energy Monochromatic Images after Contrast-Enhanced Whole-Body Imaging. AJNR Am J Neuroradiol 2018; 39:658-662. [PMID: 29439124 DOI: 10.3174/ajnr.a5558] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 12/11/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In patients with hemorrhagic contusions, hematoma volumes are overestimated on follow-up standard 120-kV images obtained after contrast-enhanced whole-body CT. We aimed to retrospectively determine hemorrhagic progression of contusion rates on 120-kV and 190-keV images derived from dual-energy CT and the magnitude of hematoma volume overestimation. MATERIALS AND METHODS We retrospectively analyzed admission and follow-up CT studies in 40 patients with hemorrhagic contusions. After annotating the contusions, we measured volumes from admission and follow-up 120-kV and 190-keV images using semiautomated 3D segmentation. Bland-Altman analysis was used for hematoma volume comparison. RESULTS On 120-kV images, hemorrhagic progression of contusions was detected in 24 of the 40 patients, while only 17 patients had hemorrhagic progression of contusions on 190-keV images (P = .008). Hematoma volumes were systematically overestimated on follow-up 120-kV images (9.68 versus 8 mm3; mean difference, 1.68 mm3; standard error, 0.37; P < .001) compared with 190-keV images. There was no significant difference in volumes between admission 120-kV and 190-keV images. Mean and median percentages of overestimation were 29% (95% CI, 18-39) and 22% (quartile 3 - quartile 1 = 36.8), respectively. CONCLUSIONS The 120-kV images, which are comparable with single-energy CT images, significantly overestimated the hematoma volumes, hence the rate of hemorrhagic progression of contusions, after contrast-enhanced whole-body CT. Hence, follow-up of hemorrhagic contusions should be performed on dual-energy CT, and 190-keV images should be used for the assessment of hematoma volumes.
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Affiliation(s)
- U K Bodanapally
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - K Shanmuganathan
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland.,Department of Environmental Health Sciences (K.S.), Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - G Issa
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - D Dreizin
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - G Li
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - K Sudini
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
| | - T R Fleiter
- From the Department of Diagnostic Radiology and Nuclear Medicine (U.K.B., K.S., G.I., D.D., G.L., T.R.F.), R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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12
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Bundles of care for resuscitation from hemorrhagic shock and severe brain injury in trauma patients-Translating knowledge into practice. J Trauma Acute Care Surg 2018; 81:780-94. [PMID: 27389129 DOI: 10.1097/ta.0000000000001161] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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13
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Shah JM, Shah KS, Kumar J, Sundaram PK. Role of routine repeat computed tomography of brain in patients with mild and moderate traumatic brain injury: A prospective study. Asian J Neurosurg 2017; 12:412-415. [PMID: 28761517 PMCID: PMC5532924 DOI: 10.4103/1793-5482.180968] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Computed tomography (CT) has become the primary investigative modality for traumatic brain injury (TBI) and there are established guidelines for the initial CT (CT-1). There are no specific guidelines for scheduling repeat CT in TBI. This study was carried out to compare the usefulness of unscheduled repeat CT (UCT-2) with scheduled repeat CT (SCT-2) in the presence or absence of neurological deterioration and to identify risk factors associated with radiological worsening (RW). METHODS This prospective study comprised admitted patients with mild and moderate TBI between February and May, 2014 and all patients were subjected to repeat CT brain. Patients with penetrating brain injuries and surgical conditions after CT-1, and age < 5 years were excluded. Positive yield after the second CT (SCT-2 and UCT-2) leading to modification of management were compared between the two groups. RESULTS In this study, 214 patients (214/222) underwent SCT-2 and 8 underwent UCT-2 (8/222). Surgery was required in 2 (0.9%) from the first group and 7 (87.5%) in the latter. UCT-2 was more likely to show RW warranting surgery as compared to SCT-2 (P < 0.05). In the SCT-2 group, CT-1 had been done within 2 h after trauma in 30 patients and 8 (8/30; 26.7%) showed RW and; after 2 h in the remaining 184 (184/214) with RW seen in 23 (23/184; 12.5%). RW was more common when the CT-1 was within 2 h from trauma (P < 0.05). In our study, the age of the patient and admission Glasgow Coma Scores did not significantly affect the findings in repeat CT. CONCLUSION Repeating CT brain is costly besides needing significant logistical support to shift an injured and often unstable patient. SCT-2 is more likely to show RW when CT-1 is done within 2 h after trauma. UCT-2 is more likely to show RW and findings warranting surgery as compared to SCT-2. Hence, a repeat CT may be preferred only in the presence of clinical worsening and when CT-1 is done within 2 h after trauma.
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Affiliation(s)
- Jayun M Shah
- Department of Neurosurgery, Goa Medical College, Goa, India
| | - Kairav S Shah
- Department of Neurosurgery, Goa Medical College, Goa, India
| | - Jinendra Kumar
- Department of Neurosurgery, Goa Medical College, Goa, India
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Volumetric analysis of day of injury computed tomography is associated with rehabilitation outcomes after traumatic brain injury. J Trauma Acute Care Surg 2017; 82:80-92. [PMID: 27805992 DOI: 10.1097/ta.0000000000001263] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Day-of-injury (DOI) brain lesion volumes in traumatic brain injury (TBI) patients are rarely used to predict long-term outcomes in the acute setting. The purpose of this study was to investigate the relationship between acute brain injury lesion volume and rehabilitation outcomes in patients with TBI at a level one trauma center. METHODS Patients with TBI who were admitted to our rehabilitation unit after the acute care trauma service from February 2009-July 2011 were eligible for the study. Demographic data and outcome variables including cognitive and motor Functional Independence Measure (FIM) scores, length of stay (LOS) in the rehabilitation unit, and ability to return to home were obtained. The DOI quantitative injury lesion volumes and degree of midline shift were obtained from DOI brain computed tomography scans. A multiple stepwise regression model including 13 independent variables was created. This model was used to predict postrehabilitation outcomes, including FIM scores and ability to return to home. A p value less than 0.05 was considered significant. RESULTS Ninety-six patients were enrolled in the study. Mean age was 43 ± 21 years, admission Glasgow Coma Score was 8.4 ± 4.8, Injury Severity Score was 24.7 ± 9.9, and head Abbreviated Injury Scale score was 3.73 ± 0.97. Acute hospital LOS was 12.3 ± 8.9 days, and rehabilitation LOS was 15.9 ± 9.3 days. Day-of-injury TBI lesion volumes were inversely associated with cognitive FIM scores at rehabilitation admission (p = 0.004) and discharge (p = 0.004) and inversely associated with ability to be discharged to home after rehabilitation (p = 0.006). CONCLUSION In a cohort of patients with moderate to severe TBI requiring a rehabilitation unit stay after the acute care hospital stay, DOI brain injury lesion volumes are associated with worse cognitive FIM scores at the time of rehabilitation admission and discharge. Smaller-injury volumes were associated with eventual discharge to home. Volumetric neuroimaging in the acute injury phase may improve surgeons' ultimate outcome predictions in TBI patients. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level V.
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15
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Gómez PA, Castaño-León AM, Lora D, Cepeda S, Lagares A. Evolución temporal en las características de la tomografía computarizada, presión intracraneal y tratamiento quirúrgico en el traumatismo craneal grave: análisis de la base de datos de los últimos 25 años en un servicio de neurocirugía. Neurocirugia (Astur) 2017; 28:1-14. [DOI: 10.1016/j.neucir.2016.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 09/05/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
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Yuan Q, Wu X, Cheng H, Yang C, Wang Y, Wang E, Qiu B, Fei Z, Lan Q, Wu S, Jiang Y, Feng H, Liu J, Liu K, Zhang F, Jiang R, Zhang J, Tu Y, Wu X, Zhou L, Hu J. Is Intracranial Pressure Monitoring of Patients With Diffuse Traumatic Brain Injury Valuable? An Observational Multicenter Study. Neurosurgery 2016; 78:361-8; discussion 368-9. [PMID: 26891376 DOI: 10.1227/neu.0000000000001050] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Although intracranial pressure (ICP) monitoring of patients with severe traumatic brain injury (TBI) is recommended by the Brain Trauma Foundation, any benefits remain controversial. OBJECTIVE To evaluate the effects of ICP monitoring on the mortality of and functional outcomes in patients with severe diffuse TBI. METHODS Data were collected on patients with severe diffuse TBI (Glasgow Coma Scale [GCS] score on admission <9 and Marshall Class II-IV) treated from January 2012 to December 2013 in 24 hospitals (17 level I trauma centers and 7 level II trauma centers) in 9 Chinese provinces. We evaluated the impact of ICP monitoring on 6-month mortality and favorable outcome using propensity score-matched analysis after controlling for independent predictors of these outcomes. RESULTS ICP monitors were inserted into 287 patients (59.5%). After propensity score matching, ICP monitoring significantly decreased 6-month mortality. ICP monitoring also had a greater impact on the most severely injured patients on the basis of head computed tomography data (Marshall computed tomography classification IV) and on patients with the lowest level of consciousness (GCS scores 3-5). After propensity score matching, monitoring remained nonassociated with a 6-month favorable outcome for the overall sample. However, monitoring had a significant impact on the 6-month favorable outcomes of patients with the lowest level of consciousness (GCS scores 3-5). CONCLUSION ICP monitor placement was associated with a significant decrease in 6-month mortality after adjustment for the baseline risk profile and the monitoring propensity of patients with diffuse severe TBI, especially those with GCS scores of 3 to 5 or of Marshall computed tomography classification IV.
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Affiliation(s)
- Qiang Yuan
- ‡Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China;§Department of Neurosurgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China;¶Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, China;‖Department of Neurosurgery, 101 Hospital of People's Liberation Army, Wuxi, China;#Department of Neurosurgery, Jinshan Hospital, Fudan University, Shanghai, China;**Department of Neurosurgery, The South Hospital of Southern Medical University, Guangzhou, China;‡‡Department of Neurosurgery, Shanghai Shuguang Hospital, Shanghai, China;§§Department of Neurosurgery, The Second Affiliated Hospital of Soochow University, Suzhou, China;¶¶Department of Emergency Medicine, The First Affiliated Hospital of Soochow University, Suzhou, China;‖‖Department of Neurosurgery, Wuxi Third People's Hospital, Wuxi, China;##Department of Neurosurgery, Southwest Hospital, Chongqing, China;***Department of Neurosurgery, Xiangya Hospital Central South University, Changsha, China;‡‡‡Department of Neurosurgery, Chongqing Emergency Medical Center, Chongqing, China;§§§Department of Neurosurgery, Enze Medical Center Luqiao Hospital, Taizhou, China;¶¶¶Department of Neurosurgery, General Hospital of Tianjing Medical University, Tianjin, China;‖‖‖Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Zhejiang, China;###Department of Neurosurgery, Affiliated Hospital of Logistics University of People's Armed Police Force, Tianjin, China
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17
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Delayed intraventricular hemorrhage in moderate-to-severe traumatic brain injury: prevalence, associated risk factors, and prognosis. Acta Neurochir (Wien) 2016; 158:1465-72. [PMID: 27294774 DOI: 10.1007/s00701-016-2854-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 05/17/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The presence of traumatic intraventricular hemorrhage (tIVH) on an admission CT scan is related to a worse outcome and increased mortality in patients with moderate and severe TBI. Currently, there is no available data regarding the predictive value of the appearance of tIVH as a delayed finding on follow-up CT scan. The purpose of this study was to determine the prevalence, associated risk factors, and prognosis of delayed tIVH. METHODS The study is based on 401 consecutive adult patients (age ≥ 18 years) with moderate-to-severe TBI admitted in our hospital for a 5-year period. At least one control CT was performed in 320 (79.8 %) patients. The prevalence of delayed tIVH was assessed and the potential risk factors and mortality were analyzed. RESULTS Delayed tIVH appeared in 38 cases (11.9 % of the second CT scans and 9.5 % of all patients). The patients with delayed tIVH are significantly older (57.39 vs. 48.63 years, p = 0.009) and developed statistically significant more frequent enlargement of an existing lesion (47.4 vs. 20.2 %, p = 0.001) and appearance of a new lesion (100 vs. 33.7 %, p < 0.001). Delayed tIVH appeared significantly more frequent in surgically treated patients with ICH as a main surgical lesion (p = 0.010) and is associated with significantly higher mortality (p < 0.001). CONCLUSIONS Delayed tIVH as a progression of injury in moderate-to-severe TBI has a relatively high occurrence and is associated with increased mortality. The only factor independently related to a new appearance of tIVH is the presence of ICH as a main surgical lesion on the control preoperative CT scans.
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Fujimoto K, Miura M, Otsuka T, Kuratsu JI. Sequential changes in Rotterdam CT scores related to outcomes for patients with traumatic brain injury who undergo decompressive craniectomy. J Neurosurg 2016; 124:1640-5. [DOI: 10.3171/2015.4.jns142760] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
Rotterdam CT scoring is a CT classification system for grouping patients with traumatic brain injury (TBI) based on multiple CT characteristics. This retrospective study aimed to determine the relationship between initial or preoperative Rotterdam CT scores and TBI prognosis after decompressive craniectomy (DC).
METHODS
The authors retrospectively reviewed the medical records of all consecutive patients who underwent DC for nonpenetrating TBI in 2 hospitals from January 2006 through December 2013. Univariate and multivariate logistic regression and receiver operating characteristic (ROC) curve analyses were used to determine the relationship between initial or preoperative Rotterdam CT scores and mortality at 30 days or Glasgow Outcome Scale (GOS) scores at least 3 months after the time of injury. Unfavorable outcomes were GOS Scores 1–3 and favorable outcomes were GOS Scores 4 and 5.
RESULTS
A total of 48 cases involving patients who underwent DC for TBI were included in this study. Univariate analyses showed that initial Rotterdam CT scores were significantly associated with mortality and both initial and preoperative Rotterdam CT scores were significantly associated with unfavorable outcomes. Multivariable logistic regression analysis adjusted for established predictors of TBI outcomes showed that initial Rotterdam CT scores were significantly associated with mortality (OR 4.98, 95% CI 1.40–17.78, p = 0.01) and unfavorable outcomes (OR 3.66, 95% CI 1.29–10.39, p = 0.02) and preoperative Rotterdam CT scores were significantly associated with unfavorable outcomes (OR 15.29, 95% CI 2.50–93.53, p = 0.003). ROC curve analyses showed cutoff values for the initial Rotterdam CT score of 5.5 (area under the curve [AUC] 0.74, 95% CI 0.59–0.90, p = 0.009, sensitivity 50.0%, and specificity 88.2%) for mortality and 4.5 (AUC 0.71, 95% CI 0.56–0.86, p = 0.02, sensitivity 62.5%, and specificity 75.0%) for an unfavorable outcome and a cutoff value for the preoperative Rotterdam CT score of 4.5 (AUC 0.81, 95% CI 0.69–0.94, p < 0.001, sensitivity 90.6%, and specificity 56.2%) for an unfavorable outcome.
CONCLUSIONS
Assessment of changes in Rotterdam CT scores over time may serve as a prognostic indicator in TBI and can help determine which patients require DC.
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Affiliation(s)
- Kenji Fujimoto
- 1Department of Neurosurgery, Japanese Red Cross Kumamoto Hospital, Higashiku
- 3Department of Neurosurgery, Faculty of Life Sciences, Kumamoto University School of Medicine, Chuo-ku, Kumamoto, Japan
| | - Masaki Miura
- 1Department of Neurosurgery, Japanese Red Cross Kumamoto Hospital, Higashiku
| | - Tadahiro Otsuka
- 2Department of Neurosurgery, National Hospital Organization Kumamoto Medical Center, Chuo-ku; and
| | - Jun-ichi Kuratsu
- 3Department of Neurosurgery, Faculty of Life Sciences, Kumamoto University School of Medicine, Chuo-ku, Kumamoto, Japan
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Waqas M, Shamim MS, Enam SF, Qadeer M, Bakhshi SK, Patoli I, Ahmad K. Predicting outcomes of decompressive craniectomy: use of Rotterdam Computed Tomography Classification and Marshall Classification. Br J Neurosurg 2016; 30:258-63. [DOI: 10.3109/02688697.2016.1139047] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Effects and Clinical Characteristics of Intracranial Pressure Monitoring-Targeted Management for Subsets of Traumatic Brain Injury: An Observational Multicenter Study. Crit Care Med 2015; 43:1405-14. [PMID: 25803654 DOI: 10.1097/ccm.0000000000000965] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To evaluate the efficacy of traumatic brain injury management guided by intracranial pressure monitoring and to explore the specific subgroups for which intracranial pressure monitoring might be significantly associated with improved outcomes based on a classification of the various traumatic brain injury pathophysiologies using the clinical features and CT scans. DESIGN Retrospective observational multicenter study. SETTING Twenty-two hospitals (16 level I trauma centers and six level II trauma centers) in nine provinces in China. PATIENTS Moderate or severe traumatic brain injury patients who were more than 14 years old. INTERVENTIONS Intracranial pressure monitoring. MEASUREMENTS AND MAIN RESULTS All data were collected by physicians from medical records. The 6-month mortality and favorable outcome were assessed with the Glasgow Outcome Scale Extended score. An intracranial pressure monitor was inserted into 838 patients (58.1%). The mean duration of intracranial pressure monitoring was 4.44 ± 3.65 days. The significant predictors of intracranial pressure monitoring included the mechanism of injury, a Glasgow Coma Scale score of 9-12 at admission that dropped to a score of 3-8 within 24 hours after injury, a Marshall CT classification of III-IV, the presence of a major extracranial injury, subdural hematoma, intraparenchymal lesions, trauma center level, and intracranial pressure monitoring utilization of hospital. The intracranial pressure monitoring and no intracranial pressure monitoring groups did not significantly differ in terms of complications. For the total sample, the placement of intracranial pressure monitoring was not associated with either 6-month mortality (16.9% vs 20.5%; p = 0.086) or 6-month unfavorable outcome (49.4% vs 45.8%; p = 0.175). For patients with a Glasgow Coma Scale score of 3-8 at admission, intracranial pressure monitoring was also not significantly associated with 6-month mortality (20.9% vs 26.0%; p = 0.053) or an unfavorable outcome (56.9% vs 55.5%; p = 0.646). Multivariate logistic regression analyses showed that intracranial pressure monitoring resulted in a significantly lower 6-month mortality for patients who had a Glasgow Coma Scale score of 3-5 at admission (adjusted odds ratio, 0.57; 95% CI, 0.36-0.90; adjusted p = 0.016), those who had a Glasgow Coma Scale score of 9-12 at admission that dropped to 3-8 within 24 hours after injury (adjusted odds ratio, 0.28; 95% CI, 0.08-0.96; adjusted p = 0.043), and those who had a probability of death at 6 months greater than 0.6 (adjusted odds ratio, 0.55; 95% CI, 0.32-0.94; adjusted p = 0.029). CONCLUSIONS There were multiple differences between the intracranial pressure monitoring and no intracranial pressure monitoring groups regarding patient characteristics, injury severity, characteristics of CT scan, and hospital type. Intracranial pressure monitoring in conjunction with intracranial pressure-targeted therapies is significantly associated with lower mortality in some special traumatic brain injury subgroups. The prospective randomized controlled trials specifically investigating these subgroups will be required to further characterize the effects of intracranial pressure monitoring on behavioral outcomes in patients with traumatic brain injury.
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Cepeda S, Gómez PA, Castaño-Leon AM, Martínez-Pérez R, Munarriz PM, Lagares A. Traumatic Intracerebral Hemorrhage: Risk Factors Associated with Progression. J Neurotrauma 2015; 32:1246-53. [PMID: 25752340 DOI: 10.1089/neu.2014.3808] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The increase in the volume of a traumatic intracerebral hemorrhage (TICH) is a widely studied phenomenon that has a direct impact on the prognosis of patients. The objective of this study was to identify the risk factors associated with the progression of TICH. We retrospectively analyzed the records of 1970 adult patients >15 years of age who were consecutively admitted after sustaining a closed severe traumatic brain injury (TBI) between January 1987 and November 2013 at a single center. Beginning in 2007, patients with moderate TBIs were also included. A total of 782 patients exhibited one or more TICH on the initial CT scan, and met the selection criteria. The main outcome variable was the presence or absence of progression of the TICH. Univariate and multivariate statistical analyses were performed. Factors independently associated with the growth of TICH obtained through logistic regression included the following: an initial volume <5 cc (odds ratio [OR] 2.42, p<0.001), cisternal compression (OR 1.95, p<0.001), decompressive craniectomy (OR 2.18, p<0.001), age (mean 37.67 vs. 42.95 years; OR 1.01, p<0.001), falls as mechanism of trauma (OR 1.72, p=0.001), multiple TICHs (OR 1.56, p=0.007), and hypoxia (OR 1.56, p=0.02). TICH progression occurred with a frequency of 63% in our study. We showed that there was a correlation between TICH growth and some variables, such as multiple TICHs, a lower initial volume, acute subdural hematoma, cisternal compression, older patient age, hypoxia, falls, and decompressive craniectomy.
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Affiliation(s)
- Santiago Cepeda
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Pedro A Gómez
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Ana María Castaño-Leon
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Rafael Martínez-Pérez
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Pablo M Munarriz
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
| | - Alfonso Lagares
- Department of Neurosurgery, Hospital 12 de Octubre, Universidad Complutense de Madrid , Madrid, Spain
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Potapov AA, Krylov VV, Gavrilov AG, Kravchuk AD, Likhterman LB, Petrikov SS, Talypov AE, Zakharova NE, Oshorov AV, Solodov AA. Guidelines for the management of severe head injury. Part 1. Neurotrauma system and neuroimaging. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2015; 79:100-106. [PMID: 26977800 DOI: 10.17116/neiro2015796100-106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Traumatic brain injury is one of the main causes of mortality and disability in young and middle-aged individuals. The patients with severe traumatic brain injury who are in coma are the most difficult to deal with. Appropriate diagnosis of the primary brain injuries and early prevention and treatment of secondary damage mechanisms largely determine the possibility of reducing mortality and severe disabling consequences. The authors compiled these guidelines based on their experience in development of international and Russian recommendations on the diagnosis and treatment of mild traumatic brain injury, penetrating gunshot injury of the skull and brain, severe traumatic brain injury, and severe consequences of brain injuries, including a vegetative state. In addition, we used the materials of international and Russian recommendations on the diagnosis, intensive care, and surgical treatment of severe traumatic brain injury published in recent years. The proposed recommendations are related to organization of medical care and diagnosis of severe traumatic brain injury in adults and are primarily addressed to neurosurgeons, neurologists, neuroradiologists, anesthesiologists, and emergency room doctors, who are routinely involved in management of these patients.
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Affiliation(s)
- A A Potapov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - V V Krylov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow
| | - A G Gavrilov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A D Kravchuk
- Burdenko Neurosurgical Institute, Moscow, Russia
| | | | - S S Petrikov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow
| | - A E Talypov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow
| | | | - A V Oshorov
- Burdenko Neurosurgical Institute, Moscow, Russia
| | - A A Solodov
- Sklifosovsky Research Institute for Emergency Medicine, Moscow
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Gómez PA, de-la-Cruz J, Lora D, Jiménez-Roldán L, Rodríguez-Boto G, Sarabia R, Sahuquillo J, Lastra R, Morera J, Lazo E, Dominguez J, Ibañez J, Brell M, de-la-Lama A, Lobato RD, Lagares A. Validation of a prognostic score for early mortality in severe head injury cases. J Neurosurg 2014; 121:1314-22. [DOI: 10.3171/2014.7.jns131874] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Traumatic brain injury (TBI) represents a large health and economic burden. Because of the inability of previous randomized controlled trials (RCTs) on TBI to demonstrate the expected benefit of reducing unfavorable outcomes, the IMPACT (International Mission on Prognosis and Analysis of Clinical Trials in TBI) and CRASH (Corticosteroid Randomisation After Significant Head Injury) studies provided new methods for performing prognostic studies of TBI. This study aimed to develop and externally validate a prognostic model for early death (within 48 hours). The secondary aim was to identify patients who were more likely to succumb to an early death to limit their inclusion in RCTs and to improve the efficiency of RCTs.
Methods
The derivation cohort was recruited at 1 center, Hospital 12 de Octubre, Madrid (1990–2003, 925 patients). The validation cohort was recruited in 2004–2006 from 7 study centers (374 patients). The eligible patients had suffered closed severe TBIs. The study outcome was early death (within 48 hours post-TBI). The predictors were selected using logistic regression modeling with bootstrapping techniques, and a penalized reduction was used. A risk score was developed based on the regression coefficients of the variables included in the final model.
Results
In the validation set, the final model showed a predictive ability of 50% (Nagelkerke R2), with an area under the receiver operating characteristic curve of 89% and an acceptable calibration (goodness-of-fit test, p = 0.32). The final model included 7 variables, and it was used to develop a risk score with a range from 0 to 20 points. Age provided 0, 1, 2, or 3 points depending on the age group; motor score provided 0 points, 2 (untestable), or 3 (no response); pupillary reactivity, 0, 2 (1 pupil reacted), or 6 (no pupil reacted); shock, 0 (no) or 2 (yes); subarachnoid hemorrhage, 0 or 1 (severe deposit); cisternal status, 0 or 3 (compressed/absent); and epidural hematoma, 0 (yes) or 2 (no). Based on the risk of early death estimated with the model, 4 risk of early death groups were established: low risk, sum score 0–3 (< 1% predicted mortality); moderate risk, sum score 4–8 (predicted mortality between 1% and 10%); high risk, sum score 9–12 (probability of early death between 10% and 50%); and very high risk, sum score 13–20 (early mortality probability > 50%). This score could be used for selecting patients for clinical studies. For example, if patients with very high risk scores were excluded from our study sample, the patients included (eligibility score < 13) would represent 80% of the original sample and only 23% of the patients who died early.
Conclusions
The combination of Glasgow Coma Scale score, CT scanning results, and secondary insult data into a prognostic score improved the prediction of early death and the classification of TBI patients.
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Affiliation(s)
| | - Javier de-la-Cruz
- 2Clinical Research Unit, IMAS12-CIBERESP, University Hospital 12 Octubre, Medical Faculty Complutense University, Madrid
| | - David Lora
- 2Clinical Research Unit, IMAS12-CIBERESP, University Hospital 12 Octubre, Medical Faculty Complutense University, Madrid
| | | | | | - Rosario Sarabia
- 4Department of Neurosurgery, Clinical University Hospital Río Ortega, Valladolid
| | - Juan Sahuquillo
- 5Department of Neurosurgery, Clinical University Hospital Val d′Hebrón, Barcelona
| | - Roberto Lastra
- 5Department of Neurosurgery, Clinical University Hospital Val d′Hebrón, Barcelona
| | - Jesus Morera
- 6Department of Neurosurgery, Clinical University Hospital Dr. Negrín, Las Palmas de Gran Canaria
| | - Eglis Lazo
- 7Department of Neurosurgery, Clinical University Hospital Virgen de la Candelaria, Tenerife
| | - Jaime Dominguez
- 7Department of Neurosurgery, Clinical University Hospital Virgen de la Candelaria, Tenerife
| | - Javier Ibañez
- 8Department of Neurosurgery, Clinical University Hospital Son Dureta, Palma de Mallorca; and
| | - Marta Brell
- 8Department of Neurosurgery, Clinical University Hospital Son Dureta, Palma de Mallorca; and
| | - Adolfo de-la-Lama
- 9Department of Neurosurgery, Clinical University Hospital, Hospital Xeral, Vigo, Spain
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24
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Isokuortti H, Luoto TM, Kataja A, Brander A, Siironen J, Liimatainen S, Iverson GL, Ylinen A, Ohman J. Necessity of monitoring after negative head CT in acute head injury. Injury 2014; 45:1340-4. [PMID: 24810669 DOI: 10.1016/j.injury.2014.04.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 04/04/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The main objective of this study was to evaluate the incidence of delayed complications in acute head injury (HI) patients with an initial normal head computed tomography (CT). MATERIALS AND METHODS This retrospective study included 3023 consecutive patients who underwent head CT due to an acute HI at the Emergency Department (ED) of Tampere University Hospital (August 2010-July 2012). Regardless of clinical injury severity, the patients with a normal head CT were selected (n=2444, 80.9%). The medical records of these patients were reviewed to identify the individuals with a serious clinically significant complication related to the primary HI. The time window considered was the following 72h after the primary head CT. A repeated head CT in the hospital ward, death, or return to the ED were indicative of a possible complication. RESULTS The majority (n=1811, 74.1%) of the patients with a negative head CT were discharged home and 1.1% (n=27) of these patients returned to ED within 72h post-CT. A repeated head CT was performed on 12 (44.4%) of the returned patients and none of the scans revealed an acute lesion. Of the 632 (25.9%) CT-negative patients admitted to the hospital ward from the ED, a head CT was repeated in 46 (7.3%) patients within 72h as part of routine practice. In the repeated CT sample, only one (0.2%) patient had a traumatic intracranial lesion. This lesion did not need neurosurgical intervention. The overall complication rate was 0.04%. CONCLUSION In the present study, which includes head injuries of all severity, the probability of delayed life-threatening complications was negligible when the primary CT scan revealed no acute traumatic lesions.
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Affiliation(s)
- Harri Isokuortti
- Department of Neurological Sciences, University of Helsinki, Helsinki, Finland.
| | - Teemu M Luoto
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Anneli Kataja
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Antti Brander
- Medical Imaging Centre, Department of Radiology, Tampere University Hospital, Tampere, Finland
| | - Jari Siironen
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Suvi Liimatainen
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Grant L Iverson
- Department of Physical Medicine and Rehabilitation, Harvard Medical School & Red Sox Foundation and Massachusetts General Hospital Home Base Program, Boston, MA, USA
| | - Aarne Ylinen
- Department of Neurological Sciences, University of Helsinki, Helsinki, Finland; Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Juha Ohman
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
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25
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Clinical outcomes in traumatic brain injury patients on preinjury clopidogrel: a prospective analysis. J Trauma Acute Care Surg 2014; 76:817-20. [PMID: 24553554 DOI: 10.1097/ta.0b013e3182aafcf0] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patients receiving antiplatelet medications are considered to be at an increased risk for traumatic intracranial hemorrhage after blunt head trauma. However, most studies have categorized all antiplatelet drugs into one category. The aim of our study was to evaluate clinical outcomes and the requirement of a repeat head computed tomography (RHCT) in patients on preinjury clopidogrel therapy. METHODS Patients with traumatic brain injury with intracranial hemorrhage on initial head CT were prospectively enrolled. Patients on preinjury clopidogrel were matched with patients exclusive of antiplatelet and anticoagulation therapy using a propensity score in a 1:1 ratio for age, Glasgow Coma Scale (GCS), head Abbreviated Injury Scale (h-AIS), Injury Severity Score (ISS), neurologic examination, and platelet transfusion. Outcome measures were progression on RHCT scan and need for neurosurgical intervention. RESULTS A total of 142 patients with intracranial hemorrhage on initial head CT scan (clopidogrel, 71; no clopidogrel, 71) were enrolled. The mean (SD) age was 70.5 (15.1) years, 66% were male, median GCS score was 14 (range, 3-15), and median h-AIS (ISS) was 3 (range, 2-5). The mean (SD) platelet count was 210 (101), and 61% (n = 86) of the patients received platelet transfusion. Patients on preinjury clopidogrel were more likely to have progression on RHCT (odds ratio [OR], 5.1; 95% confidence interval [CI], 3.1-7.1) and RHCT as a result of clinical deterioration (OR, 2.1; 95% CI, 1.8-3.5). The overall rate of neurosurgical intervention was 4.2% (n = 6). Patients on clopidogrel therapy were more likely to require a neurosurgical intervention (OR, 1.8; 95% CI, 1.4-3.1). CONCLUSION Preinjury clopidogrel therapy is associated with progression of initial insult on RHCT scan and need for neurosurgical intervention. Preinjury clopidogrel therapy as an independent variable should warrant the need for a routine RHCT scan in patients with traumatic brain injury. LEVEL OF EVIDENCE Prognostic study, level I; therapeutic study, level II.
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26
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Reljic T, Mahony H, Djulbegovic B, Etchason J, Paxton H, Flores M, Kumar A. Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis. J Neurotrauma 2013; 31:78-98. [PMID: 23914924 DOI: 10.1089/neu.2013.2873] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Diagnosis and management of traumatic brain injury (TBI) is crucial to improve patient outcomes. While initial head computed tomography (CT) scan is the optimum tool for quick and accurate detection of intracranial hemorrhage, the guidelines on use of repeat CT differ among institutions. Three systematic reviews have been conducted on a similar topic; none have performed a comprehensive meta-analysis of all studies. Search of Medline, the Cochrane Library database, and Clinicaltrials.gov , and a hand search of conference abstracts and references for all completed studies reporting data on change in management following repeat CT was conducted. Two authors reviewed all studies and extracted data using a standardized form. A proportional meta-analysis was conducted using the random-effects model for outcomes related to any change in management following repeat CT. Any change in management included intracranial intervention, change in intracranial pressure monitoring, and/or administration of drug therapy. Search results yielded 6982 references. In all, 41 studies enrolling 10,501 patients were included. Change in management following repeat CT was reported in 13 prospective and 28 retrospective studies and yielded a pooled proportion of 11.4% (95% confidence interval [CI] 5.9-18.4) and 9.6% (95% CI 6.5-13.2), respectively. In a subgroup analysis of mild TBI patients (Glasgow Coma Scale score 13 to 15), five prospective and nine retrospective studies reported on change in management following repeat CT with the pooled proportion across prospective studies at 2.3% (95% CI 0.3-6.3) and across retrospective studies at 3.9% (95% CI 2.3-5.7), respectively. The evidence suggests that repeat CT in patients with TBI results in a change in management for only a minority of patients. Better designed studies are needed to address the issue of the value of repeat CT in the management of TBI.
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Affiliation(s)
- Tea Reljic
- 1 Center for Evidence Based Medicine and Health Outcomes Research, University of South Florida , Tampa, Florida
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27
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Jacobs B, Beems T, van der Vliet TM, van Vugt AB, Hoedemaekers C, Horn J, Franschman G, Haitsma I, van der Naalt J, Andriessen TMJC, Borm GF, Vos PE. Outcome Prediction in Moderate and Severe Traumatic Brain Injury: A Focus on Computed Tomography Variables. Neurocrit Care 2012; 19:79-89. [DOI: 10.1007/s12028-012-9795-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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28
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Serum levels of ubiquitin C-terminal hydrolase distinguish mild traumatic brain injury from trauma controls and are elevated in mild and moderate traumatic brain injury patients with intracranial lesions and neurosurgical intervention. J Trauma Acute Care Surg 2012; 72:1335-44. [PMID: 22673263 DOI: 10.1097/ta.0b013e3182491e3d] [Citation(s) in RCA: 150] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND This study compared early serum levels of ubiquitin C-terminal hydrolase (UCH-L1) from patients with mild and moderate traumatic brain injury (TBI) with uninjured and injured controls and examined their association with traumatic intracranial lesions on computed tomography (CT) scan (CT positive) and the need for neurosurgical intervention (NSI). METHODS This prospective cohort study enrolled adult patients presenting to three tertiary care Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score 9 to 15. Control groups included normal uninjured controls and nonhead injured trauma controls presenting to the emergency department with orthopedic injuries or motor vehicle crash without TBI. Blood samples were obtained in all trauma patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for UCH-L1 (ng/mL ± standard error of the mean). RESULTS There were 295 patients enrolled, 96 TBI patients (86 with GCS score 13-15 and 10 with GCS score 9-12), and 199 controls (176 uninjured, 16 motor vehicle crash controls, and 7 orthopedic controls). The AUC for distinguishing TBI from uninjured controls was 0.87 (95% confidence interval [CI], 0.82-0.92) and for distinguishing those TBIs with GCS score 15 from controls was AUC 0.87 (95% CI, 0.81-0.93). Mean UCH-L1 levels in patients with CT negative versus CT positive were 0.620 (± 0.254) and 1.618 (± 0.474), respectively (p < 0.001), and the AUC was 0.73 (95% CI, 0.62-0.84). For patients without and with NSI, levels were 0.627 (0.218) versus 2.568 (0.854; p < 0.001), and the AUC was 0.85 (95% CI, 0.76-0.94). CONCLUSION UCH-L1 is detectable in serum within an hour of injury and is associated with measures of injury severity including the GCS score, CT lesions, and NSI. Further study is required to validate these findings before clinical application. LEVEL OF EVIDENCE II, prognostic study.
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29
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Gradisek P, Osredkar J, Korsic M, Kremzar B. Multiple indicators model of long-term mortality in traumatic brain injury. Brain Inj 2012; 26:1472-81. [PMID: 22721420 DOI: 10.3109/02699052.2012.694567] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine the prognostic ability of protein S100B, neuron-specific enolase (NSE) and glial fibrillary acid protein (GFAP) for prediction of 1-year mortality in patients with traumatic brain injury (TBI) in relation to clinical and radiological characteristics of TBI. METHODS Brain injury was quantified in 84 patients (Glasgow Coma Scale [GCS] ≤ 12) using clinical (GCS, pupils), radiological (computed tomography [CT] classification and individual CT characteristics) and biochemical (S100B, NSE and GFAP) data at admission and in the acute post-injury period. RESULTS Initial and peak S100B, NSE and GFAP concentrations were higher in non-survivors (n = 26) than in survivors (p-value range: <0.001-0.018). Cox regression showed that GFAP and S100B concentration and the temporal profile of S100B were more powerful independent predictors of mortality than baseline clinical and radiological characteristics or clinical and radiological indicators of neurological deterioration. The prognostic models containing admission variables and those available during the subsequent clinical course showed the same discrimination ability (area under receiver characteristic curve 0.92), but the model based on variables available in the acute post-injury period calibrated better (p = 0.428). CONCLUSION Mortality at 1-year post-TBI is accurately predicted by the combination of GFAP and S100B concentration and clinical and radiological characteristics at admission or in the acute post-injury period.
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Affiliation(s)
- Primoz Gradisek
- Clinical Department of Anaesthesiology and Intensive Therapy, Centre for Intensive Therapy, University Medical Centre, Ljubljana, Slovenia.
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30
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Dynamics of brain tissue changes induced by traumatic brain injury assessed with the Marshall, Morris-Marshall, and the Rotterdam classifications and its impact on outcome in a prostacyclin placebo-controlled study. Acta Neurochir (Wien) 2012; 154:1069-79. [PMID: 22538327 DOI: 10.1007/s00701-012-1345-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2012] [Accepted: 03/27/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND The present study evaluates the types and dynamics of intracranial pathological changes in patients with severe traumatic brain injury (sTBI) who participated in a prospective, randomized, double-blinded study of add-on treatment with prostacyclin. Further, the changes of brain CT scan and their correlation to Glasgow Coma Scale score (GCS), maximal intracranial pressure (ICP(max)), minimal cerebral perfusion pressure (CPP(min)), and Glasgow Outcome Score (GOS) at 3, 6, and 12 months were studied. METHODS Forty-eight subjects with severe traumatic brain injury were treated according to an ICP-targeted therapy protocol based on the Lund concept with the addition of prostacyclin or placebo. The first available CT scans (CT(i)) and follow-up scans nearest to 24 h (CT(24)) were evaluated using the Marshall, Rotterdam, and Morris-Marshall classifications. RESULTS There was a significant correlation of the initial Marshall, Rotterdam, Morris-Marshall classifications and GOS at 3 and 12 months. The CT(24) Marshall classification did not significantly correlate to GOS while the Rotterdam and the Morris-Marshall classification did. The CT(i) Rotterdam classification predicted outcome evaluated as GOS at 3 and 12 months. Prostacyclin treatment did not influence the dynamic of tissue changes. CONCLUSIONS The Rotterdam classification seems to be appropriate for describing the evolution of the injuries on the CT scans and contributes in predicting of outcome in patients treated with an ICP-targeted therapy. The Morris-Marshall classification can also be used for prognostication of outcome but it describes only the impact of traumatic subarachnoid hemorrhage (tSAH).
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Huang YH, Deng YH, Lee TC, Chen WF. Rotterdam Computed Tomography Score as a Prognosticator in Head-Injured Patients Undergoing Decompressive Craniectomy. Neurosurgery 2012; 71:80-5. [DOI: 10.1227/neu.0b013e3182517aa1] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
The Rotterdam computed tomography (CT) score was developed for prognostic purposes in traumatic brain injury (TBI).
OBJECTIVE:
To examine the prognostic discrimination and prediction of the Rotterdam CT score in the case of patients undergoing decompressive craniectomy (DC) for TBI.
METHODS:
The CT scans with the worst findings before DC were scored according to the Rotterdam CT classification. Mortality and Glasgow Outcome Scale score at the end of follow-up were used as outcome measures. Unfavorable and favorable outcomes were defined by a Glasgow Outcome Scale score of 1 to 3 and 4 to 5, respectively. We used binary logistic and proportional odds regression for prognostic analyses.
RESULTS:
The relationship between the Rotterdam CT score and prognosis was quantified, and higher scores indicated worse patient outcomes. Univariate analysis showed that the Rotterdam CT score was significantly associated with mortality (odds ratio: 3.117, 95% confidence interval: 1.867-5.386; P < .001) and unfavorable outcomes (odds ratio: 2.612, 95% confidence interval: 1.733-3.939; P < .001). After adjustment for published outcome predictors of TBI in multivariate regression, the Rotterdam CT score remained an independent predictor of unfavorable outcomes (odds ratio: 1.830, 95% confidence interval: 1.043-3.212; P = .035).
CONCLUSION:
For head-injured patients undergoing DC, the Rotterdam CT score provides great prognostic discrimination and is an independent predictor of unfavorable outcomes. We suggest that the Rotterdam CT score be included as a prognosticator in the overall assessment of clinical condition of TBI patients before DC.
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Affiliation(s)
- Yu-Hua Huang
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Han Deng
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Tao-Chen Lee
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Wu-Fu Chen
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung, Taiwan
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Papa L, Lewis LM, Falk JL, Zhang Z, Silvestri S, Giordano P, Brophy GM, Demery JA, Dixit NK, Ferguson I, Liu MC, Mo J, Akinyi L, Schmid K, Mondello S, Robertson CS, Tortella FC, Hayes RL, Wang KKW. Elevated levels of serum glial fibrillary acidic protein breakdown products in mild and moderate traumatic brain injury are associated with intracranial lesions and neurosurgical intervention. Ann Emerg Med 2011; 59:471-83. [PMID: 22071014 DOI: 10.1016/j.annemergmed.2011.08.021] [Citation(s) in RCA: 228] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Revised: 08/24/2011] [Accepted: 08/30/2011] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE This study examines whether serum levels of glial fibrillary acidic protein breakdown products (GFAP-BDP) are elevated in patients with mild and moderate traumatic brain injury compared with controls and whether they are associated with traumatic intracranial lesions on computed tomography (CT) scan (positive CT result) and with having a neurosurgical intervention. METHODS This prospective cohort study enrolled adult patients presenting to 3 Level I trauma centers after blunt head trauma with loss of consciousness, amnesia, or disorientation and a Glasgow Coma Scale (GCS) score of 9 to 15. Control groups included normal uninjured controls and trauma controls presenting to the emergency department with orthopedic injuries or a motor vehicle crash without traumatic brain injury. Blood samples were obtained in all patients within 4 hours of injury and measured by enzyme-linked immunosorbent assay for GFAP-BDP (nanograms/milliliter). RESULTS Of the 307 patients enrolled, 108 were patients with traumatic brain injury (97 with GCS score 13 to 15 and 11 with GCS score 9 to 12) and 199 were controls (176 normal controls and 16 motor vehicle crash controls and 7 orthopedic controls). Receiver operating characteristic curves demonstrated that early GFAP-BDP levels were able to distinguish patients with traumatic brain injury from uninjured controls with an area under the curve of 0.90 (95% confidence interval [CI] 0.86 to 0.94) and differentiated traumatic brain injury with a GCS score of 15 with an area under the curve of 0.88 (95% CI 0.82 to 0.93). Thirty-two patients with traumatic brain injury (30%) had lesions on CT. The area under these curves for discriminating patients with CT lesions versus those without CT lesions was 0.79 (95% CI 0.69 to 0.89). Moreover, the receiver operating characteristic curve for distinguishing neurosurgical intervention from no neurosurgical intervention yielded an area under the curve of 0.87 (95% CI 0.77 to 0.96). CONCLUSION GFAP-BDP is detectable in serum within an hour of injury and is associated with measures of injury severity, including the GCS score, CT lesions, and neurosurgical intervention. Further study is required to validate these findings before clinical application.
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Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, FL, USA.
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Diffuse Axonal Injury in Patients With Head Injuries: An Epidemiologic and Prognosis Study of 124 Cases. ACTA ACUST UNITED AC 2011; 71:838-46. [PMID: 21460740 DOI: 10.1097/ta.0b013e3182127baa] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Sonographic optic nerve sheath diameter as an estimate of intracranial pressure in adult trauma. J Surg Res 2011; 170:265-71. [PMID: 21550065 DOI: 10.1016/j.jss.2011.03.009] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 02/16/2011] [Accepted: 03/03/2011] [Indexed: 12/22/2022]
Abstract
BACKGROUND Intracranial pressure (ICP) is currently measured with invasive monitoring. Sonographic optic nerve sheath diameter (ONSD) may provide a noninvasive estimate of ICP. Our hypothesis was that bedside ONSD accurately estimates ICP in acutely injured patients. The specific aims were (1) to determine the accuracy of ONSD in estimating elevated ICP, (2) to correlate ONSD and ICP in unilateral and bilateral head injuries, and (3) to determine the effect of ICP monitor placement on ONSD measurements. MATERIALS AND METHODS A blinded prospective study of adult trauma patients requiring ICP monitoring was performed at a University-based urban trauma center. The ONSD was measured by ultrasound pre- and post-placement of an ICP monitor (Camino Bolt or Ventriculostomy). RESULTS One-hundred fourteen measurements were obtained in 10 trauma patients requiring ICP monitoring. Pre- and post-ONSD were compared with side of injury in the presence of an ICP monitor. ROC analysis demonstrated ONSD poorly estimates elevated ICP (AUC = 0.36). Overall sensitivity, specificity, PPV, NPV, and accuracy for estimating ICP with ONSD were 36%, 38%, 40%, 16%, and 37%. Poor correlation of ONSD to ICP was observed with unilateral (R(2) = 0.45, P < 0.01) and bilateral (R(2) = 0.21, P = 0.01) injuries. ICP monitor placement did not affect ONSD measurements on the right (P = 0.5), left (P = 0.4), or right and left sides combined (P = 0.3). CONCLUSIONS Sonographic ONSD as a surrogate for elevated ICP in lieu of invasive monitoring is not reliable due to poor accuracy and correlation.
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Jacobs B, Beems T, van der Vliet TM, Diaz-Arrastia RR, Borm GF, Vos PE. Computed Tomography and Outcome in Moderate and Severe Traumatic Brain Injury: Hematoma Volume and Midline Shift Revisited. J Neurotrauma 2011; 28:203-15. [DOI: 10.1089/neu.2010.1558] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Affiliation(s)
- Bram Jacobs
- Department of Neurology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Tjemme Beems
- Department of Neurosurgery, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Ton M. van der Vliet
- Department of Radiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Ramon R. Diaz-Arrastia
- Department of Neurology, University of Texas, Southwestern Medical Center, Dallas, Texas
| | - George F. Borm
- Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Pieter E. Vos
- Department of Neurology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
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Alahmadi H, Vachhrajani S, Cusimano MD. The natural history of brain contusion: an analysis of radiological and clinical progression. J Neurosurg 2010; 112:1139-45. [DOI: 10.3171/2009.5.jns081369] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Although brain contusions are a common neurosurgical condition, surprisingly little has been written about their natural history. The purpose of this study was to identify factors that predict radiological and clinically significant progression of this pattern of traumatic brain injury in patients who did not initially require surgery. On the basis of their results and the available literature, the authors suggest a management algorithm.
Methods
The authors performed a retrospective review of clinical and radiological records of consecutive patients with brain contusions who initially underwent conservative treatment. Significant radiological progression was defined as a 30% increase in contusion size on CT scans. Statistical analysis was performed to identify clinical and radiological predictors of CT contusion progression, the significance of progression, and predictors of clinical outcome.
Results
Of 98 patients identified with brain contusions who initially received conservative treatment, 44 (45%) had significant progression on CT, and 19 (19%) required surgical intervention. The initial size of the contusion and the presence of subdural hematoma were the only statistically significant predictors of CT progression in the multivariate analysis (p = 0.0212 and 0.05, respectively). Four patients required delayed contusion evacuation (3 had radiological progression on follow-up scans). Good Glasgow Coma Scale (GCS) scores on presentation and younger age were predictors of eventual discharge from the hospital (OR 1.471, CI 1.233–1.755, p < 0.001 and OR 0.949, CI 0.912–0.988, p = 0.011, respectively). No patients with an initial GCS score of 15 or an initial contusion size < 14 ml required delayed evacuation.
Conclusions
Contusion progression is a common phenomenon that is seen more commonly in larger contusions. Patients with large contusions and low initial GCS scores are at risk for delayed deterioration. A proposed management algorithm for patients with contusions initially treated conservatively may help practitioners identify the best course of treatment.
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Swanson EW, Mascitelli J, Stiefel M, MacMurtrie E, Levine J, Kofke WA, Yang W, Le Roux PD. Patient Transport and Brain Oxygen in Comatose Patients. Neurosurgery 2010; 66:925-31; discussion 931-2. [DOI: 10.1227/01.neu.0000368543.59446.a4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
Transport of critically ill intensive care unit patients may be hazardous. We examined whether brain oxygen (brain tissue oxygen partial pressure [PbtO2]) is influenced by transport to and from a follow-up head computed tomography (transport head computed tomography [tHCT]) scan.
METHODS
Forty-five patients (24 men, 21 women; Glasgow Coma Scale score ≤8; mean age, 47.3 ± 19.0 years) who had a traumatic brain injury (n = 26) or subarachnoid hemorrhage (n = 19) were retrospectively identified from a prospective observational cohort of PbtO2 monitoring in a neurosurgical intensive care unit at a university-based level I trauma center. PbtO2, intracranial pressure, and cerebral perfusion pressure were monitored continuously and compared during the 3 hours before and after 100 tHCT scans.
RESULTS
The mean PbtO2 before and after the tHCT scans for all 100 scans was 37.9 ± 19.8 mm Hg and 33.9 ± 17.2 mm Hg, respectively (P = .0001). A decrease in PbtO2 (>5%) occurred after 54 tHCTs (54%) and in 36 patients (80%). In instances in which a decrease occurred, the average decrease in mean, minimum, and maximum PbtO2 was 23.6%, 29%, and 18.1%, respectively. This decrease was greater when PbtO2 was compromised (<25 mm Hg) before tHCT. An episode of brain hypoxia (<15 mm Hg) was identified in the 3 hours before tHCT in 9 and after tHCT in 19 instances. On average, an episode of brain hypoxia was 46.6 ± 16.0 (standard error) minutes longer after tHCT than before tHCT (P = .008). Multivariate analysis suggests that changes in lung function (PaO2/fraction of inspired oxygen [FiO2] ratio) may account for the reduced PbtO2 after tHCT (parameter estimate 0.45, 95% confidence interval: 0.024–0.871; P = .04).
CONCLUSION
These data suggest that transport to and from the intensive care unit may adversely affect PbtO2. This deleterious effect is greater when PbtO2 is already compromised and may be associated with lung function.
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Affiliation(s)
- Edward W. Swanson
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Justin Mascitelli
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Stiefel
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eileen MacMurtrie
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua Levine
- Departments of Neurosurgery, Neurology, and Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - W. Andrew Kofke
- Departments of Neurosurgery, Neurology, and Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Wei Yang
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter D. Le Roux
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Thomas BW, Mejia VA, Maxwell RA, Dart BW, Smith PW, Gallagher MR, Claar SC, Greer SH, Barker DE. Scheduled Repeat CT Scanning for Traumatic Brain Injury Remains Important in Assessing Head Injury Progression. J Am Coll Surg 2010; 210:824-30, 831-2. [DOI: 10.1016/j.jamcollsurg.2009.12.039] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2009] [Accepted: 12/30/2009] [Indexed: 11/27/2022]
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Jacobs B, Beems T, van der Vliet TM, Borm GF, Vos PE. The Status of the Fourth Ventricle and Ambient Cisterns Predict Outcome in Moderate and Severe Traumatic Brain Injury. J Neurotrauma 2010; 27:331-40. [DOI: 10.1089/neu.2009.1105] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Bram Jacobs
- Department of Neurology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Tjemme Beems
- Department of Neurosurgery, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Ton M. van der Vliet
- Department of Radiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - George F. Borm
- Department of Epidemiology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - Pieter E. Vos
- Department of Neurology, Biostatistics and HTA, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
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Laalo JP, Kurki TJ, Sonninen PH, Tenovuo OS. Reliability of Diagnosis of Traumatic Brain Injury by Computed Tomography in the Acute Phase. J Neurotrauma 2009; 26:2169-78. [DOI: 10.1089/neu.2009.1011] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jussi P. Laalo
- Medical Imaging Centre, Turku University Central Hospital, Turku, Finland
| | | | - Pirkko H. Sonninen
- Medical Imaging Centre, Turku University Central Hospital, Turku, Finland
- Pulssi Medical Imaging Centre, Turku, Finland
| | - Olli S. Tenovuo
- Department of Neurology, Turku University Central Hospital, Turku, Finland
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Zhu GW, Wang F, Liu WG. Classification and prediction of outcome in traumatic brain injury based on computed tomographic imaging. J Int Med Res 2009; 37:983-95. [PMID: 19761680 DOI: 10.1177/147323000903700402] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Traumatic brain injury (TBI) is a common and potentially devastating problem. The classification of TBI is necessary for accurate diagnosis and the prediction of outcomes. The increased use of early sedation, intubation and ventilation in more severely injured patients has decreased the value of the Glasgow Coma Scale for the purposes of classification. An alternative is the classification of TBI according to morphological criteria based on computed tomography (CT) investigations. This article reviews the current classification and prediction of outcomes in TBI based on CT imaging. Classifications based on the presence or absence of intracranial local lesions, diffuse injury, signs of subarachnoid or intra-ventricular haemorrhage and fractures or foreign bodies are considered, and their predictive value is discussed. Future studies should address the complicated issue of how optimally to combine CT characteristics for prognostic purposes and how to improve on currently used CT classifications to predict outcomes more accurately.
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Affiliation(s)
- G W Zhu
- Department of Neurosurgery, Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou City, Zhejiang Province, China
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Early Progression of Traumatic Cerebral Contusions: Characterization and Risk Factors. ACTA ACUST UNITED AC 2009; 67:508-14; discussion 514-5. [DOI: 10.1097/ta.0b013e3181b2519f] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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The role of MR imaging in assessing prognosis after severe and moderate head injury. Acta Neurochir (Wien) 2009; 151:341-56. [PMID: 19224121 DOI: 10.1007/s00701-009-0194-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2009] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
Abstract
PURPOSE The objective of this work is two-fold: to determine the role of MRI findings in establishing the prognosis of patients with moderate and severe traumatic brain injury (TBI) admitted to our centre, measured with different outcome scales; and to determine in which patients the information given by MR findings adds prognostic information to that from traditional prognostic factors. METHODS One hundred patients suffering moderate or severe head injury in whom MRI had been performed in the first 30 days after trauma were included. The MRI was evaluated by two neuroradiologists who were not aware of the initial CT results or the clinical situation of the patients. Outcome was determined 6 months after head injury by means of the extended version of the Glasgow Outcome Scale. The prognostic capacity of the different factors related to outcome was compared by the analysis of receiver operating characteristic (ROC) curves and the area under the curve (AUC) for each factor. RESULTS There exists a clear relation between the depth of the traumatic lesions shown on MRI, and their classification by the proposed scale, and the outcome of patients suffering traumatic brain injury determined by different scales 6 months after injury. CONCLUSIONS The anatomical substrate of TBI depicted by MRI could be a useful prognostic tool in patients suffering moderate and severe head injury. Patients with a score of 4 or less on the motor subscale of the GCS scale are those who could benefit most from the prognostic information provided by MRI.
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Value of Repeat Cranial Computed Tomography in Pediatric Patients Sustaining Moderate to Severe Traumatic Brain Injury. ACTA ACUST UNITED AC 2008; 65:1293-7. [DOI: 10.1097/ta.0b013e318156866c] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Boto GR, Gómez PA, De la Cruz J, Lobato RD. A historical analysis of severe head injury. Neurosurg Rev 2008; 32:343-53; discussion 353-4. [DOI: 10.1007/s10143-008-0178-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2008] [Revised: 08/01/2008] [Accepted: 09/18/2008] [Indexed: 11/24/2022]
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Narayan RK, Maas AIR, Servadei F, Skolnick BE, Tillinger MN, Marshall LF. Progression of traumatic intracerebral hemorrhage: a prospective observational study. J Neurotrauma 2008; 25:629-39. [PMID: 18491950 DOI: 10.1089/neu.2007.0385] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
ABSTRACT Preliminary evidence has shown that intracerebral hemorrhages, either spontaneous (sICH) or traumatic (tICH) often expand over time. An association between hemorrhage expansion and clinical outcomes has been described for sICH. The intent of this prospective, observational study was to characterize the temporal profile of hemorrhage progression, as measured by serial computed tomography (CT) scanning, with the aim of better understanding the natural course of hemorrhage progression in tICH. There was also a desire to document the baseline adverse event (AE) profile in this patient group. An important motive for performing this study was to set the stage for subsequent studies that will examine the role of a new systemic hemostatic agent in tICH. Subjects were enrolled if they had tICH lesions of at least 2 mL on a baseline CT scan obtained within 6 h of a head injury. CT scans were repeated at 24 and 72 h. Clinical outcomes and pre-defined AEs were documented. The data showed that 51% of the subjects demonstrated an increase in tICH volume, and that most of the increase occurred early. In addition, larger hematomas exhibited the greatest expansion. Thromboembolic complications were identified in 13% of subjects. This study demonstrates that tICH expansion between the baseline and 24-h CT scans occurred in approximately half of the subjects. The earlier after injury that the initial CT scan is obtained, the greater is the likelihood that the hematoma will expand on subsequent scans. The time frame during which hemorrhagic expansion occurs provides an opportunity for early intervention to limit a process with adverse prognostic implications.
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Affiliation(s)
- Raj K Narayan
- Department of Neurosurgery, University of Cincinnati, The Neuroscience Institute at University Hospital and The Mayfield Clinic, 231 Albert Sabin Way, Cincinnati, OH 45267, USA.
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Narayan RK, Maas AIR, Marshall LF, Servadei F, Skolnick BE, Tillinger MN. Recombinant factor VIIA in traumatic intracerebral hemorrhage: results of a dose-escalation clinical trial. Neurosurgery 2008; 62:776-86; discussion 786-8. [PMID: 18496183 DOI: 10.1227/01.neu.0000316898.78371.74] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVE Intracerebral hemorrhages, whether spontaneous or traumatic (tICH), often expand, and an association has been described between hemorrhage expansion and worse clinical outcomes. Recombinant factor VIIa (rFVIIa) is a hemostatic agent that has been shown to limit hemorrhage expansion and which, therefore, could potentially reduce morbidity and mortality in tICH. This first prospective, randomized, placebo-controlled, dose-escalation study evaluated the safety and preliminary effectiveness of rFVIIa to limit tICH progression. METHODS Patients were enrolled if they had tICH lesions of at least 2 ml on a baseline computed tomographic scan obtained within 6 hours of injury. rFVIIa or placebo was administered within 2.5 hours of the baseline computed tomographic scan but no later than 7 hours after injury. Computed tomographic scans were repeated at 24 and 72 hours. Five escalating dose tiers were evaluated (40, 80, 120, 160, and 200 microg/kg rFVIIa). Clinical evaluations and adverse events were recorded until Day 15. RESULTS No significant differences were detected in mortality rate or number and type of adverse events among treatment groups. Asymptomatic deep vein thrombosis, detected on routinely performed ultrasound at Day 3, was observed more frequently in the combined rFVIIa treatment group (placebo, 3%; rFVIIa, 8%; not significant). A nonsignificant trend for rFVIIa dose-response to limit tICH volume increase was observed (placebo, 21.0 ml; rFVIIa, 10.1 ml). CONCLUSION In this first prospective study of rFVIIa in tICH, there appeared to be less hematoma progression in rFVIIa-treated patients (80-200 microg/kg) compared with that seen in placebo treated patients. The potential significance of this biological effect on clinical outcomes and the significance of the somewhat higher incidence of ultrasound-detected deep vein thromboses in the rFVIIa-treated group need to be examined in a larger prospective randomized clinical trial.
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Affiliation(s)
- Raj K Narayan
- Department of Neurosurgery, University of Cincinnati, Cincinnati, Ohio, USA
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Routine Serial Computed Tomographic Scans in Mild Traumatic Brain Injury: When are They Cost-Effective? ACTA ACUST UNITED AC 2008; 65:66-72. [DOI: 10.1097/ta.0b013e318068d75f] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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49
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Zhang J, Groff RF, Chen XH, Browne KD, Huang J, Schwartz ED, Meaney DF, Johnson VE, Stein SC, Rojkjaer R, Smith DH. Hemostatic and neuroprotective effects of human recombinant activated factor VII therapy after traumatic brain injury in pigs. Exp Neurol 2008; 210:645-55. [PMID: 18291370 PMCID: PMC3979422 DOI: 10.1016/j.expneurol.2007.12.019] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 12/07/2007] [Accepted: 12/13/2007] [Indexed: 12/26/2022]
Abstract
Human recombinant activated factor-VII (rFVIIa) has been used successfully in the treatment of spontaneous intracerebral hemorrhage. In addition, there is increasing interest in its use to treat uncontrolled bleeding of other origins, including trauma. The aim of this study was to evaluate the safety and potential effectiveness of rFVIIa to mitigate bleeding using a clinically relevant model of traumatic brain injury (TBI) in the pig. A double injury model was chosen consisting of (1) an expanding cerebral contusion induced by the application of negative pressure to the exposed cortical surface and (2) a rapid rotational acceleration of the head to induce diffuse axonal injury (DAI). Injuries were performed on 10 anesthetized pigs. Five minutes after injury, 720 microg/kg rFVIIa (n=5) or vehicle control (n=5) was administered intravenously. Magnetic resonance imaging (MRI) studies were performed within 30 min and at 3 days post-TBI to determine the temporal expansion of the cerebral contusion. Euthanasia and histopathologic analysis were performed at day 3. This included observations for hippocampal neuronal degeneration, axonal pathology and microclot formation. The expansion of contusion volume over the 3 days post-injury period was reduced significantly in animals treated with rFVIIa compared to vehicle controls. Surprisingly, immunohistochemical analysis demonstrated that the number of dead/dying hippocampal neurons and axonal pathology was reduced substantially by rFVIIa treatment compared to vehicle. In addition, there was no difference in the extent of microthrombi between groups. rFVIIa treatment after TBI in the pig reduced expansion of hemorrhagic cerebral contusion volume without exacerbating the severity of microclot formation. Finally, rFVIIa treatment provided a surprising neuroprotective effect by reducing hippocampal neuron degeneration as well as the extent of DAI.
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Affiliation(s)
- Jun Zhang
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
- Department of Neurosurgery, PLA General Hospital, Beijing, China
| | - Robert F. Groff
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Xiao-Han Chen
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Kevin D. Browne
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Jason Huang
- Department of Neurological Surgery, University of Rochester, School of Medicine and Dentistry, Rochester, NY 14642, USA
| | - Eric D. Schwartz
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
| | - David F. Meaney
- Department of Bioengineering, The University of Pennsylvania, Philadelphia PA19104, USA
| | - Victoria E. Johnson
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | - Sherman C. Stein
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
| | | | - Douglas H. Smith
- Department of Neurosurgery and Penn Center for Brain Injury and Repair, University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Turtz AR, Goldman HW. Head Injury. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50069-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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