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Sakkas A, Weiß C, Wilde F, Ebeling M, Thiele OC, Mischkowski RA, Pietzka S. Impact of antithrombotic therapy on acute and delayed intracranial haemorrhage and evaluation of the need of short-term hospitalisation based on CT findings after mild traumatic brain injury: experience from an oral and maxillofacial surgery unit. Eur J Trauma Emerg Surg 2024; 50:157-172. [PMID: 36707437 DOI: 10.1007/s00068-023-02228-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 01/13/2023] [Indexed: 01/28/2023]
Abstract
PURPOSE The primary aim was to compare the prevalence of acute and delayed intracranial haemorrhage (ICH) following mild traumatic brain injury (mTBI) in patients on antithrombotic medication referred to a clinic for oral and plastic maxillofacial surgery. The secondary aim was to evaluate the need for short-term hospitalisation based on initial radiological and clinical findings. METHODS This was an observational retrospective single-centre study of all patients on antithrombotic medication who were admitted to our department of oral and plastic maxillofacial surgery with mTBI over a 5 year period. Demographic and anamnesis data, injury characteristics, antithrombotic medication, radiological findings, treatment, and outcome were analysed. Patients were divided into the following four groups based on their antithrombotic medication: (1) single antiplatelet users, (2) vitamin K antagonist users, (3) direct oral anticoagulant users, and (4) double antithrombotic users. All patients underwent an emergency cranial CT (CT0) at admission. Based on clinical and radiological evaluation, different treatment protocols were applied. Patients with positive CT0 findings and patients with secondary neurological deterioration received a control CT (CT1) before discharge. Acute and delayed ICH and patient's outcome during hospitalisation were evaluated using descriptive statistical analysis. RESULTS A total of 696 patients (mean age, 71.6 years) on antithrombotic medication who presented at our department with mTBI were included in the analysis. Most injuries were caused by a ground-level fall (76.9%). Thirty-six patients (5.1%) developed an acute traumatic ICH, and 47 intracerebral lesions were detected by radiology-most of these in patients taking acetylsalicylic acid. No association was detected between ICH and antithrombotic medication (p = 0.4353). In total, 258 (37.1%) patients were admitted for 48 h in-hospital observation. The prevalence of delayed ICH was 0.1%, and the mortality rate was 0.1%. Multivariable analysis identified a Glasgow Coma Scale (GCS) of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea as clinical characteristics significantly associated with an increased risk of acute ICH, whereas age, sex, and trauma mechanism were not associated with ICH prevalence. Of the 39 patients who underwent a control CT1, most had a decreasing or at least constant intracranial lesion; in three patients, intracranial bleeding increased but was not clinically relevant. CONCLUSION According to our experience, antithrombotic therapy does not increase the rate of ICH after mTBI. A GCS of < 15, loss of consciousness, amnesia, headache, dizziness, and nausea are indicators of higher ICH risk. A second CT scan is more effective in patients with secondary neurological deterioration. Initial CT findings were not clinically relevant and should not indicate in-hospital observation.
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Affiliation(s)
- Andreas Sakkas
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany.
| | - Christel Weiß
- Medical Statistics and Biomathematics, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Frank Wilde
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany
| | - Marcel Ebeling
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
| | | | | | - Sebastian Pietzka
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, Ulm, Germany
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Sakkas A, Weiß C, Ebeling M, Wilde F, Pietzka S, Mohammad Q, Thiele OC, Mischkowski RA. Clinical Indicators for Primary Cranial CT Imaging after Mild Traumatic Brain Injury-A Retrospective Analysis. J Clin Med 2023; 12:jcm12103563. [PMID: 37240668 DOI: 10.3390/jcm12103563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/08/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
The primary aim was to determine the clinical indicators for primary cranial CT imaging in patients after mild traumatic brain injury (mTBI). The secondary aim was to evaluate the need for post-traumatic short-term hospitalization based on primary clinical and CT findings. This was an observational retrospective single-centre study of all the patients who were admitted with mTBI over a five-year period. Demographic and anamnesis data, the clinical and radiological findings, and the outcome were analyzed. An initial cranial CT (CT0) was performed at admission. Repeat CT scans (CT1) were performed after positive CT0 findings and in cases with in-hospital secondary neurological deterioration. Intracranial hemorrhage (ICH) and the patient's outcome were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between the clinical variables and the pathologic CT findings. A total of 1837 patients (mean age: 70.7 years) with mTBI were included. Acute ICH was detected in 102 patients (5.5%), with a total of 123 intracerebral lesions. In total, 707 (38.4%) patients were admitted for 48 h for in-hospital observation and six patients underwent an immediate neurosurgical intervention. The prevalence of delayed ICH was 0.05%. A Glasgow Coma Scale (GCS) of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of fracture were identified as clinical factors with significantly higher risk of acute ICH. None of the 110 CT1 presented clinical relevance. A GCS of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures should be considered absolute indicators for primary cranial CT imaging. The reported incidence of immediate and delayed traumatic ICH was very low and hospitalization should be decided individually considering both the clinical and CT findings.
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Affiliation(s)
- Andreas Sakkas
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Christel Weiß
- Medical Statistics and Biomathematics, University Medical Centre Mannheim, Heidelberg University, 69167 Mannheim, Germany
| | - Marcel Ebeling
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Frank Wilde
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Sebastian Pietzka
- Department of Cranio-Maxillo-Facial-Surgery, University Hospital Ulm, 89081 Ulm, Germany
- Department of Cranio-Maxillo-Facial-Surgery, German Armed Forces Hospital Ulm, 89081 Ulm, Germany
| | - Qasim Mohammad
- Institute for Diagnostic and Interventional Radiology, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
| | - Oliver Christian Thiele
- Department of Cranio-Maxillo-Facial-Surgery, Ludwigshafen Hospital, 67063 Ludwigshafen, Germany
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Janigro D, Mondello S, Posti JP, Unden J. GFAP and S100B: What You Always Wanted to Know and Never Dared to Ask. Front Neurol 2022; 13:835597. [PMID: 35386417 PMCID: PMC8977512 DOI: 10.3389/fneur.2022.835597] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 02/03/2022] [Indexed: 12/19/2022] Open
Abstract
Traumatic brain injury (TBI) is a major global health issue, with outcomes spanning from intracranial bleeding, debilitating sequelae, and invalidity with consequences for individuals, families, and healthcare systems. Early diagnosis of TBI by testing peripheral fluids such as blood or saliva has been the focus of many research efforts, leading to FDA approval for a bench-top assay for blood GFAP and UCH-L1 and a plasma point-of-care test for GFAP. The biomarker S100B has been included in clinical guidelines for mTBI (mTBI) in Europe. Despite these successes, several unresolved issues have been recognized, including the robustness of prior data, the presence of biomarkers in tissues beyond the central nervous system, and the time course of biomarkers in peripheral body fluids. In this review article, we present some of these issues and provide a viewpoint derived from an analysis of existing literature. We focus on two astrocytic proteins, S100B and GFAP, the most commonly employed biomarkers used in mTBI. We also offer recommendations that may translate into a broader acceptance of these clinical tools.
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Affiliation(s)
- Damir Janigro
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, OH, United States.,FloTBI, Cleveland, OH, United States
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Jussi P Posti
- Department of Neurosurgery, Neurocenter, Turku Brain Injury Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Johan Unden
- Department of Operation and Intensive Care, Hallands Hospital Halmstad, Lund University, Lund, Sweden
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Shih RY, Burns J, Ajam AA, Broder JS, Chakraborty S, Kendi AT, Lacy ME, Ledbetter LN, Lee RK, Liebeskind DS, Pollock JM, Prall JA, Ptak T, Raksin PB, Shaines MD, Tsiouris AJ, Utukuri PS, Wang LL, Corey AS. ACR Appropriateness Criteria® Head Trauma: 2021 Update. J Am Coll Radiol 2021; 18:S13-S36. [PMID: 33958108 DOI: 10.1016/j.jacr.2021.01.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/14/2021] [Indexed: 12/13/2022]
Abstract
Head trauma (ie, head injury) is a significant public health concern and is a leading cause of morbidity and mortality in children and young adults. Neuroimaging plays an important role in the management of head and brain injury, which can be separated into acute (0-7 days), subacute (<3 months), then chronic (>3 months) phases. Over 75% of acute head trauma is classified as mild, of which over 75% have a normal Glasgow Coma Scale score of 15, therefore clinical practice guidelines universally recommend selective CT scanning in this patient population, which is often based on clinical decision rules. While CT is considered the first-line imaging modality for suspected intracranial injury, MRI is useful when there are persistent neurologic deficits that remain unexplained after CT, especially in the subacute or chronic phase. Regardless of time frame, head trauma with suspected vascular injury or suspected cerebrospinal fluid leak should also be evaluated with CT angiography or thin-section CT imaging of the skull base, respectively. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
| | - Judah Burns
- Panel Chair, Montefiore Medical Center, Bronx, New York
| | | | - Joshua S Broder
- Duke University School of Medicine, Durham, North Carolina, American College of Emergency Physicians, Residency Program Director for Emergency Medicine, Vice Chief for Education, Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine
| | - Santanu Chakraborty
- Ottawa Hospital Research Institute and the Department of Radiology, The University of Ottawa, Ottawa, Ontario, Canada, Canadian Association of Radiologists, CAR representative in ACR Quality Commission
| | - A Tuba Kendi
- Mayo Clinic, Rochester, Minnesota, Head of Nuclear Medicine Therapies at Mayo Clinic
| | - Mary E Lacy
- University of New Mexico, Albuquerque, New Mexico, American College of Physicians
| | | | - Ryan K Lee
- Einstein Healthcare Network, Philadelphia, Pennsylvania
| | - David S Liebeskind
- University of California Los Angeles, Los Angeles, California, American Academy of Neurology, President of SVIN
| | - Jeffrey M Pollock
- Oregon Health and Science University, Portland, Oregon, Editor, ACR Case in Point; Functional MRI Director, Oregon Health and Science University
| | - J Adair Prall
- Littleton Adventist Hospital, Littleton, Colorado, Neurosurgery expert, Chair, Guidelines Committee, Joint Section for Trauma and Critical Care
| | - Thomas Ptak
- R. Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, Vice Chair of Community Radiology, University of Maryland Medical Center, Chief of Emergency and Trauma Imaging, R Adams Cowley Shock Trauma Center
| | - P B Raksin
- John H. Stroger Jr Hospital of Cook County, Chicago, Illinois, Neurosurgery expert, Chair Elect, American Association of Neurological Surgeons/Congress of Neurological Surgeons Section on Neurotrauma & Neurocritical Care; Vice Chair, American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Guidelines Review Committee; Director, Neurosurgery ICU
| | - Matthew D Shaines
- Albert Einstein College of Medicine Montefiore Medical Center, Bronx, New York, Internal Medicine Physician, Associate Program Director for the Moses-Weiler Internal Medicine Residency Program, Albert Einstein College of Medicine; Associate Chief, Division of Hospital Medicine
| | | | | | - Lily L Wang
- University of Cincinnati Medical Center, Cincinnati, Ohio, Neuroradiology Fellowship Program Director
| | - Amanda S Corey
- Specialty Chair, Atlanta VA Health Care System and Emory University, Atlanta, Georgia
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Posti JP, Takala RSK, Lagerstedt L, Dickens AM, Hossain I, Mohammadian M, Ala-Seppälä H, Frantzén J, van Gils M, Hutchinson PJ, Katila AJ, Maanpää HR, Menon DK, Newcombe VF, Tallus J, Hrusovsky K, Wilson DH, Gill J, Sanchez JC, Tenovuo O, Zetterberg H, Blennow K. Correlation of Blood Biomarkers and Biomarker Panels with Traumatic Findings on Computed Tomography after Traumatic Brain Injury. J Neurotrauma 2019; 36:2178-2189. [PMID: 30760178 DOI: 10.1089/neu.2018.6254] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The aim of the study was to examine the ability of eight protein biomarkers and their combinations in discriminating computed tomography (CT)-negative and CT-positive patients with traumatic brain injury (TBI), utilizing highly sensitive immunoassays in a well-characterized cohort. Blood samples were obtained from 160 patients with acute TBI within 24 h of admission. Levels of β-amyloid isoforms 1-40 (Aβ40) and 1-42 (Aβ42), glial fibrillary acidic protein (GFAP), heart fatty-acid binding protein (H-FABP), interleukin 10 (IL-10), neurofilament light (NF-L), S100 calcium-binding protein B (S100B), and tau were measured. Patients were divided into CT-negative (n = 65) and CT-positive (n = 95), and analyses were conducted separately for TBIs of all severities (Glasgow Coma Scale [GCS] score 3-15) and mild TBIs (mTBIs; GCS 13-15). NF-L, GFAP, and tau were the best in discriminating CT-negative and CT-positive patients, both in patients with mTBI and with all severities. In patients with all severities, area under the curve of the receiver operating characteristic (AUC) was 0.822, 0.817, and 0.781 for GFAP, NF-L, and tau, respectively. In patients with mTBI, AUC was 0.720, 0.689, and 0.676, for GFAP, tau, and NF-L, respectively. The best panel of three biomarkers for discriminating CT-negative and CT-positive patients in the group of all severities was a combination of GFAP+H-FABP+IL-10, with a sensitivity of 100% and specificity of 38.5%. In patients with mTBI, the best panel of three biomarkers was H-FABP+S100B+tau, with a sensitivity of 100% and specificity of 46.4%. Panels of biomarkers outperform individual biomarkers in separating CT-negative and CT-positive patients. Panels consisted mainly of different biomarkers than those that performed best as an individual biomarker.
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Affiliation(s)
- Jussi P Posti
- 1 Department of Neurosurgery, Turku University Hospital, Turku, Finland.,2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,3 Department of Neurology, University of Turku, Turku, Finland
| | - Riikka S K Takala
- 2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,4 Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Finland
| | - Linnéa Lagerstedt
- 5 Department of Specialities of Internal Medicine, University of Geneva, Geneva, Switzerland
| | - Alex M Dickens
- 6 Turku Center for Biotechnology, University of Turku, Turku, Finland
| | - Iftakher Hossain
- 1 Department of Neurosurgery, Turku University Hospital, Turku, Finland.,2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,3 Department of Neurology, University of Turku, Turku, Finland
| | - Mehrbod Mohammadian
- 2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,3 Department of Neurology, University of Turku, Turku, Finland
| | - Henna Ala-Seppälä
- 2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,3 Department of Neurology, University of Turku, Turku, Finland
| | - Janek Frantzén
- 1 Department of Neurosurgery, Turku University Hospital, Turku, Finland.,3 Department of Neurology, University of Turku, Turku, Finland
| | - Mark van Gils
- 7 VTT Technical Research Center of Finland Ltd., Tampere, Finland
| | - Peter J Hutchinson
- 8 Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ari J Katila
- 2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,5 Department of Specialities of Internal Medicine, University of Geneva, Geneva, Switzerland
| | - Henna-Riikka Maanpää
- 1 Department of Neurosurgery, Turku University Hospital, Turku, Finland.,2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,3 Department of Neurology, University of Turku, Turku, Finland
| | - David K Menon
- 9 Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Virginia F Newcombe
- 9 Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Jussi Tallus
- 2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,3 Department of Neurology, University of Turku, Turku, Finland.,10 Department of Radiology, Turku University Hospital, Turku, Finland
| | | | | | - Jessica Gill
- 12 National Institute of Nursing Research, National Institutes of Health, Bethesda, Maryland
| | - Jean-Charles Sanchez
- 5 Department of Specialities of Internal Medicine, University of Geneva, Geneva, Switzerland
| | - Olli Tenovuo
- 2 Turku Brain Injury Center, Turku University Hospital, Turku, Finland.,3 Department of Neurology, University of Turku, Turku, Finland
| | - Henrik Zetterberg
- 13 Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,14 Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,15 Department of Neurodegenerative Disease, University College London, London, United Kingdom.,16 UK Dementia Research Institute at UCL, University College London, London, United Kingdom
| | - Kaj Blennow
- 13 Department of Psychiatry and Neurochemistry, Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,14 Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
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Posti JP, Hossain I, Takala RSK, Liedes H, Newcombe V, Outtrim J, Katila AJ, Frantzén J, Ala-Seppälä H, Coles JP, Kyllönen A, Maanpää HR, Tallus J, Hutchinson PJ, van Gils M, Menon DK, Tenovuo O. Glial Fibrillary Acidic Protein and Ubiquitin C-Terminal Hydrolase-L1 Are Not Specific Biomarkers for Mild CT-Negative Traumatic Brain Injury. J Neurotrauma 2017; 34:1427-1438. [PMID: 27841729 DOI: 10.1089/neu.2016.4442] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase-L1 (UCH-L1) have been studied as potential biomarkers of mild traumatic brain injury (mTBI). We report the levels of GFAP and UCH-L1 in patients with acute orthopedic injuries without central nervous system involvement, and relate them to the type of extracranial injury, head magnetic resonance imaging (MRI) findings, and levels of GFAP and UCH-L1 in patients with CT-negative mTBI. Serum UCH-L1 and GFAP were longitudinally measured from 73 patients with acute orthopedic injury on arrival and on days 1, 2, 3, 7 after admission, and on the follow-up visit 3-10 months after the injury. The injury types were recorded, and 71% patients underwent also head MRI. The results were compared with those found in patients with CT-negative mTBI (n = 93). The levels of GFAP were higher in patients with acute orthopedic trauma than in patients with CT-negative mTBI (p = 0.026) on arrival; however, no differences were found on the following days. The levels of UCH-L1 were not significantly different between these two groups at any measured point of time. Levels of GFAP and UCH-L1 were not able to distinguish patients with CT-negative mTBI from patients with orthopedic trauma. Patients with orthopedic trauma and high levels of UCH-L1 or GFAP values may be falsely diagnosed as having a concomitant mTBI, predisposing them to unwarranted diagnostics and unnecessary brain imaging. This casts a significant doubt on the diagnostic value of GFAP and UCH-L1 in cases with mTBI.
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Affiliation(s)
- Jussi P Posti
- 1 Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital , Turku, Finland
- 2 Division of Clinical Neurosciences, Department of Rehabilitation and Brain Trauma, Turku University Hospital , Turku, Finland
- 3 Department of Neurology, University of Turku , Turku, Finland
| | | | - Riikka S K Takala
- 4 Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku , Turku, Finland
| | - Hilkka Liedes
- 5 Systems Medicine, VTT Technical Research Centre of Finland Ltd , Tampere, Finland
| | - Virginia Newcombe
- 6 Division of Anaesthesia, Department of Medicine, University of Cambridge , Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Joanne Outtrim
- 6 Division of Anaesthesia, Department of Medicine, University of Cambridge , Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Ari J Katila
- 4 Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku , Turku, Finland
| | - Janek Frantzén
- 1 Division of Clinical Neurosciences, Department of Neurosurgery, Turku University Hospital , Turku, Finland
- 2 Division of Clinical Neurosciences, Department of Rehabilitation and Brain Trauma, Turku University Hospital , Turku, Finland
| | | | - Jonathan P Coles
- 7 Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge , Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Anna Kyllönen
- 3 Department of Neurology, University of Turku , Turku, Finland
| | | | - Jussi Tallus
- 3 Department of Neurology, University of Turku , Turku, Finland
| | - Peter J Hutchinson
- 7 Department of Clinical Neurosciences, Neurosurgery Unit, University of Cambridge , Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Mark van Gils
- 5 Systems Medicine, VTT Technical Research Centre of Finland Ltd , Tampere, Finland
| | - David K Menon
- 6 Division of Anaesthesia, Department of Medicine, University of Cambridge , Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Olli Tenovuo
- 2 Division of Clinical Neurosciences, Department of Rehabilitation and Brain Trauma, Turku University Hospital , Turku, Finland
- 3 Department of Neurology, University of Turku , Turku, Finland
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