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Kamaludin AI, Amoo M, Henry J, Geoghegan P, Curley GF, O'Brien DP, Javadpour M. Evaluation of severe traumatic brain injury referrals to the National Tertiary Neurosurgical Centre in the Republic of Ireland. Surgeon 2024; 22:125-129. [PMID: 38071143 DOI: 10.1016/j.surge.2023.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 03/19/2024]
Abstract
BACKGROUND Transfer of all severe TBI patients to a neurosurgical unit (NSU) has been advocated irrespective of levels of complexity and prognostic factors. Previous publications have suggested that only 50% of severe TBI patients in Ireland were managed in NSUs. AIMS This study aims to audit severe TBI referrals to the National Neurosurgical Centre, to evaluate reasons for nonacceptance, assess for differences in the transferred and not transferred cohorts and to analyse observed and expected mortality rates. METHODS Data on all patients with TBI referred in 2021 were prospectively collected using an electronic referral system. Patients with severe TBI (GCS ≤ 8 and AIS ≥ 3) were included and dichotomised into transferred and not transferred cohorts. RESULTS Of 118 patients referred with severe TBI, 45 patients (38.1%) were transferred to the neurosurgical centre. Patients in the transferred cohort were significantly younger (p < 0.001), had a higher GCS score (p < 0.001) and a lower proportion of bilaterally unreactive pupils (p < 0.001) compared to the not transferred cohort. 93% (68/73) of those not transferred were either >65 years old, or had bilaterally unreactive pupils, or both. Based on the IMPACT model, the observed to expected mortality ratios in the transferred and not transferred cohorts were 0.65 (95% CI 0.25-1.05) and 0.88 (95% CI 0.65-1.11) respectively. CONCLUSION The observed mortality rate for severe TBI in Ireland was similar to or better than expected mortality rates when adjusted for important prognostic factors. 93% of severe TBI patients not transferred to a neurosurgical centre were either elderly or had bilaterally unreactive pupils or both. These patients have an extremely poor prognosis and recommendation for transfer cannot be made based on current available evidence.
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Affiliation(s)
- Ahmad I Kamaludin
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Michael Amoo
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Jack Henry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Pierce Geoghegan
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Gerard F Curley
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - David P O'Brien
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland; Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Academic Neurology, Trinity College Dublin, Dublin, Ireland.
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Sallie A, Wise R. Outcomes of traumatic brain injury patients in an adult intensive care unit of a South African regional hospital, without on-site neurosurgical service: A retrospective quantitative study on the neurological improvement at discharge. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2023; 39:e1286. [PMID: 38357691 PMCID: PMC10866207 DOI: 10.7196/sajcc.2023.v39i3.1286] [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] [Accepted: 11/24/2023] [Indexed: 02/16/2024] Open
Abstract
Background Traumatic brain injury (TBI) is a major cause of mortality and disability. The South African (SA) province of Kwazulu-Natal faces challenges in providing appropriate care for TBI patients owing to limited resources and delayed access to healthcare services. We aimed to assess the outcomes of patients with TBI who were treated at a hospital without a neurosurgical unit (NSU). Objectives The primary objective was to compare the Glasgow Coma Scale (GCS) scores at admission and discharge from the intensive care unit (ICU) for patients with TBI receiving neuroprotection. Secondary objectives included analysing demographics and identifying predictive factors associated with GCS score improvement. Methods This retrospective study analysed data from the already established ICU Integrated Critical Care Electronic Database. Data on patient demographics, mechanisms of injury and GCS scores were collected and analysed. Results The analysis included 95 TBI patients, most of whom were young males. Interpersonal violence and transport-related trauma were the main causes of injury among patients. Approximately 63% of patients had a GCS score improvement >1 upon discharge from the ICU. Patients who received >12 hours of neuroprotection in the emergency department had significantly lower rates of improvement. Conclusion Sixty-three percent of TBI patients had improved GCS scores by >1 on discharge from the ICU, but outcomes varied. Delayed ICU admission from the emergency department of >12 hours might contribute to worse outcomes. Timely neuroprotection, improved access to neurosurgical care and better understanding of the factors affecting outcomes are needed. Contribution of the study This study explores the outcomes of patients with TBI admitted to a non-neurosurgical ICU. Factors contributing to a worse outcome are identified, highlighting the need for adequate numbers of ICU beds and prompt admission from the emergency department.
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Affiliation(s)
- A Sallie
- Discipline of Anaesthesiology, and Critical Care, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - R Wise
- Faculty Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Belgium
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford University Hospitals Trust, Oxford, United Kingdom
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Sarma AK, Popli G, Anzalone A, Contillo N, Cornell C, Nunn AM, Rowland JA, Godwin DW, Flashman LA, Couture D, Stapleton-Kotloski JR. Use of magnetic source imaging to assess recovery after severe traumatic brain injury-an MEG pilot study. Front Neurol 2023; 14:1257886. [PMID: 38020602 PMCID: PMC10656620 DOI: 10.3389/fneur.2023.1257886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023] Open
Abstract
Rationale Severe TBI (sTBI) is a devastating neurological injury that comprises a significant global trauma burden. Early comprehensive neurocritical care and rehabilitation improve outcomes for such patients, although better diagnostic and prognostic tools are necessary to guide personalized treatment plans. Methods In this study, we explored the feasibility of conducting resting state magnetoencephalography (MEG) in a case series of sTBI patients acutely after injury (~7 days), and then about 1.5 and 8 months after injury. Synthetic aperture magnetometry (SAM) was utilized to localize source power in the canonical frequency bands of delta, theta, alpha, beta, and gamma, as well as DC-80 Hz. Results At the first scan, SAM source maps revealed zones of hypofunction, islands of preserved activity, and hemispheric asymmetry across bandwidths, with markedly reduced power on the side of injury for each patient. GCS scores improved at scan 2 and by scan 3 the patients were ambulatory. The SAM maps for scans 2 and 3 varied, with most patients showing increasing power over time, especially in gamma, but a continued reduction in power in damaged areas and hemispheric asymmetry and/or relative diminishment in power at the site of injury. At the group level for scan 1, there was a large excess of neural generators operating within the delta band relative to control participants, while the number of neural generators for beta and gamma were significantly reduced. At scan 2 there was increased beta power relative to controls. At scan 3 there was increased group-wise delta power in comparison to controls. Conclusion In summary, this pilot study shows that MEG can be safely used to monitor and track the recovery of brain function in patients with severe TBI as well as to identify patient-specific regions of decreased or altered brain function. Such MEG maps of brain function may be used in the future to tailor patient-specific rehabilitation plans to target regions of altered spectral power with neurostimulation and other treatments.
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Affiliation(s)
- Anand Karthik Sarma
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Neurocritical Care, Piedmont Atlanta Hospital, Atlanta, GA, United States
| | - Gautam Popli
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Anthony Anzalone
- Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI, United States
| | - Nicholas Contillo
- Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Cassandra Cornell
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Andrew M. Nunn
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Jared A. Rowland
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Research and Education Department, W.G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
| | - Dwayne W. Godwin
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Research and Education Department, W.G. (Bill) Hefner VA Healthcare System, Salisbury, NC, United States
| | - Laura A. Flashman
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Daniel Couture
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, NC, United States
| | - Jennifer R. Stapleton-Kotloski
- Department of Neurology, Wake Forest University School of Medicine, Winston-Salem, NC, United States
- Department of Neurobiology and Anatomy, Wake Forest University School of Medicine, Winston-Salem, NC, United States
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Xu L, Wang Z, Wu T, Zhao M, Wu Y, Huang Y, Chen J, Sharma A, Sharma HS. Innovative emergency strategies for patients with severe traumatic brain injury: An IoT-based resource integration. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2023; 171:301-316. [PMID: 37783560 DOI: 10.1016/bs.irn.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Severe traumatic brain injury patients are in critical condition, and rapid rescue is very important for prognosis. Currently, the resuscitation process is complex and it is difficult to get to the operating room quickly to target treatment. We present a new strategy based on the Internet of Things system to integrate complex first aid procedures for efficient and comprehensive rescuing of patients with severe traumatic brain injury. This system includes three modules: human sign monitoring equipment, emergency transport equipment, and a network diagnosis and treatment progress control center. The system not only supports the streamlining of rescue procedures but also transmits the patient's status and optimal treatment strategies in real-time by using an advanced Internet of Things system. After deploying the system in a hospital, we conducted a validation study to evaluate its feasibility and superiority in clinical use. The preliminary results of the study show that this system can significantly shorten the treatment time, which may help the prognosis of severe traumatic brain injury patients.
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Affiliation(s)
- Longbiao Xu
- Department of Neurosurgery, The Third Affiliated Hospital of Zhejiang Chinese Medical University, P.R. China
| | - Zhe Wang
- Linping Hospital of Traditional Chinese Medicine, Hangzhou City, Zhejiang Province, China
| | - Tianya Wu
- Department of Neurosurgery, Zhuji Affiliated Hospital of Shaoxing University, Zhuji People's Hospital of Zhejiang Province, P.R. China
| | - Ming Zhao
- Department of Neurosurgery, Zhuji Affiliated Hospital of Shaoxing University, Zhuji People's Hospital of Zhejiang Province, P.R. China
| | - Ying Wu
- Department of Neurosurgery, Zhuji Affiliated Hospital of Shaoxing University, Zhuji People's Hospital of Zhejiang Province, P.R. China
| | - Yubo Huang
- The Third School of Clinical Medicine, Zhejiang Chinese Medical University, P.R. China
| | - Jie Chen
- Department of Neurosurgery, Zhuji Affiliated Hospital of Shaoxing University, Zhuji People's Hospital of Zhejiang Province, P.R. China
| | - Aruna Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Dept. of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
| | - Hari Shanker Sharma
- International Experimental Central Nervous System Injury & Repair (IECNSIR), Dept. of Surgical Sciences, Anesthesiology & Intensive Care Medicine, Uppsala University Hospital, Uppsala University, Uppsala, Sweden.
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Atkinson E, Dickman R. Growth factors and their peptide mimetics for treatment of traumatic brain injury. Bioorg Med Chem 2023; 90:117368. [PMID: 37331175 DOI: 10.1016/j.bmc.2023.117368] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/16/2023] [Accepted: 06/05/2023] [Indexed: 06/20/2023]
Abstract
Traumatic brain injury (TBI) is a leading cause of disability in adults, caused by a physical insult damaging the brain. Growth factor-based therapies have the potential to reduce the effects of secondary injury and improve outcomes by providing neuroprotection against glutamate excitotoxicity, oxidative damage, hypoxia, and ischemia, as well as promoting neurite outgrowth and the formation of new blood vessels. Despite promising evidence in preclinical studies, few neurotrophic factors have been tested in clinical trials for TBI. Translation to the clinic is not trivial and is limited by the short in vivo half-life of the protein, the inability to cross the blood-brain barrier and human delivery systems. Synthetic peptide mimetics have the potential to be used in place of recombinant growth factors, activating the same downstream signalling pathways, with a decrease in size and more favourable pharmacokinetic properties. In this review, we will discuss growth factors with the potential to modulate damage caused by secondary injury mechanisms following a traumatic brain injury that have been trialled in other indications including spinal cord injury, stroke and neurodegenerative diseases. Peptide mimetics of nerve growth factor (NGF), hepatocyte growth factor (HGF), glial cell line-derived growth factor (GDNF), brain-derived neurotrophic factor (BDNF), platelet-derived growth factor (PDGF) and fibroblast growth factor (FGF) will be highlighted, most of which have not yet been tested in preclinical or clinical models of TBI.
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Affiliation(s)
- Emily Atkinson
- School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK; UCL Centre for Nerve Engineering, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK.
| | - Rachael Dickman
- School of Pharmacy, University College London, 29-39 Brunswick Square, London WC1N 1AX, UK.
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Tonkins M, Bouamra O, Lecky F. Association between major trauma centre care and outcomes of adult patients injured by low falls in England and Wales. Emerg Med J 2023; 40:257-263. [PMID: 36759172 DOI: 10.1136/emermed-2022-212393] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 01/24/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Disability and death due to low falls is increasing worldwide and disproportionately affects older adults. Current trauma systems were not designed to suit the needs of these patients. This study assessed the association between major trauma centre (MTC) care and outcomes in adult patients injured by low falls. METHODS Data were obtained from the Trauma Audit and Research Network on adult patients injured by falls from <2 m between 2017 and 2019 in England and Wales. 30-day survival, length of hospital stay and discharge destination were compared between MTCs and trauma units or local emergency hospitals (TU/LEHs) using an adjusted multiple logistic regression model. RESULTS 127 334 patients were included, of whom 27.6% attended an MTC. The median age was 79.4 years (IQR 64.5-87.2 years), and 74.2% of patients were aged >65 years. MTC care was not associated with improved 30-day survival (adjusted OR (AOR) 0.91, 95% CI 0.87 to 0.96, p<0.001). Transferred patients had a significant impact on the results. After excluding transferred patients, MTC care was associated with greater odds of 30-day survival (AOR 1.056, 95% CI 1.001 to 1.113, p=0.044). MTC care was also associated with greater odds of 30-day survival in the most severely injured patients (AOR 1.126, 95% CI 1.04 to 1.22, p=0.002), but not in patients aged >65 years (AOR 1.038, 95% CI 0.982 to 1.097, p=0.184). CONCLUSION MTC care was not associated with improved survival compared with TU/LEH care in the whole cohort. Patients who were transferred had a significant impact on the results. In patients who are not transferred, MTC care is associated with greater odds of 30-day survival in the whole cohort and in the most severely injured patients. Future research must determine the optimum means of identifying patients in need of higher-level care, the components of care which improve patient outcomes, develop patient-focused outcomes which reflect the characteristics and priorities of contemporary trauma patients, and investigate the need for transfer in specific subgroups of patients.
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Affiliation(s)
- Michael Tonkins
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Omar Bouamra
- The Trauma Audit and Research Network, Salford, UK
| | - Fiona Lecky
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
- The Trauma Audit and Research Network, Salford, UK
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Alqurashi N, Alotaibi A, Bell S, Lecky F, Body R. Towards exploring current challenges and future opportunities relating to the prehospital triage of patients with traumatic brain injury: a mixed-methods study protocol. BMJ Open 2023; 13:e068555. [PMID: 36882243 PMCID: PMC10008429 DOI: 10.1136/bmjopen-2022-068555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a major global health burden that results in disability and loss of health. Identifying those patients who require specialist neuroscience care can be challenging due to the low accuracy of existing prehospital trauma triage tools. Despite the widespread use of decision aids to 'rule out' TBI in hospitals, they are not widely used in the prehospital environment. We aim to provide a snapshot of current prehospital practices in the UK, and to explore facilitators and challenges that may be encountered when adopting new tools for decision support. METHODS AND ANALYSIS A mixed-methods study will be conducted using a convergent design approach. In the first phase, we will conduct a national survey of current practice in which every participating ambulance service in the UK will receive an online questionnaire, and only one response is required. In the second phase, semistructured interviews will be conducted to explore the perceptions of ambulance service personnel regarding the implementation of new triage methods that may enhance triage decisions. The survey questions and the interview topic guide were piloted and externally reviewed. Quantitative data will be summarised using descriptive statistics; qualitative data will be analysed thematically. ETHICS AND DISSEMINATION This study has been approved by the Health Research Authority (REC reference 22/HRA/2035). Our findings may inform the design of future care pathways and research as well as identify challenges and opportunities for future development of prehospital triage tools for patients with suspected TBI. Our findings will be published in peer-reviewed journals, relevant national and international conferences, and will be included in a PhD thesis.
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Affiliation(s)
- Naif Alqurashi
- Department of Accidents and Trauma, Prince Sultan bin Abdelaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Ahmed Alotaibi
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
- College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Steve Bell
- Medical Directorate, North West Ambulance Service NHS Trust, Bolton, UK
| | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Richard Body
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
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Gilmartin S, Brent L, Hanrahan M, Dunphy M, Deasy C. A retrospective review of patients who sustained traumatic brain injury in Ireland 2014-2019. Injury 2022; 53:3680-3691. [PMID: 36167689 DOI: 10.1016/j.injury.2022.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 08/30/2022] [Accepted: 09/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is the most significant cause of death and disability resulting from major trauma. The aim of this study is to describe the demographics of TBI patients, the current pathways of care and outcomes in the Republic of Ireland from 2014 to 2019. METHODS We performed a retrospective review of all TBI patients meeting inclusion criteria in Ireland's Major Trauma Audit (MTA) from 2014 to 2019. Severe TBI was defined as an abbreviated injury scale (AIS) ≥3 and GCS ≤8. RESULTS During the study period, 30,891 patients sustained major trauma meeting inclusion criteria for MTA, of which 7,393 (23.9%) patients met the inclusion criteria for TBI; 1,025 (13.9%) were classified as severe. The median age was 60.6 years (IQR 36.9-78.0), 54.3 years (32.8-73.4) for males and 71.7 years (50.0-83.0) for females (p<0.001). Of patients with severe TBI, 185 (18.0%) were brought direct to a neurosurgical centre, 389 (37.9%) were transferred to a neurosurgical centre and 321 (31.3%) had a neurosurgical intervention performed. In patients sustaining severe TBI, older patients (Adjusted OR, 0.96,95% CI 0.95-0.97) and patients requiring another surgery (OR 0.31, 95%CI 0.18-0.53) were less likely to be secondarily transferred to a neurosurgical centre. There were 47 (4.6%) patients with severe TBI discharged to rehabilitation. The 30-day mortality in Ireland was 11.6% in all TBI patients and 45.5% in severe TBI patients. Older patients and patients with higher ISS had a higher chance of death. Male patients, patients treated in neurosurgical centre, patients who had neurosurgery or non-neurosurgical surgery had a higher chance of survival. CONCLUSION This population-based study bench marks the 'as is' for patients with TBI in Ireland. We found that presently in Ireland, the mortality rate from severe TBI appears to be higher than that reported in international literature, and only a minority of severe TBI patients are brought directly from the incident to a neurosurgical centre. The new major trauma system should focus on providing effective and efficient access to neurosurgical, neuro-critical and neuro-rehabilitative care for patients who sustain TBI.
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Affiliation(s)
- Stephen Gilmartin
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland.
| | - Louise Brent
- Major Trauma Audit, National Office of Clinical Audit, Ireland
| | | | - Michael Dunphy
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland
| | - Conor Deasy
- Department of Emergency Medicine, Cork University Hospital, Cork, Ireland; Major Trauma Audit, National Office of Clinical Audit, Ireland
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Peterman N, Smith EJ, Liang E, Yeo E, Kaptur B, Naik A, Arnold PM, Hassaneen W. Geospatial evaluation of disparities in neurosurgical access in the United States. J Clin Neurosci 2022; 105:109-114. [PMID: 36148727 DOI: 10.1016/j.jocn.2022.09.001] [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: 02/27/2022] [Revised: 08/15/2022] [Accepted: 09/02/2022] [Indexed: 11/25/2022]
Abstract
When neurosurgical care is needed, the distance to a facility staffed with a neurosurgeon is critical. This work utilizes geospatial analysis to analyze access to neurosurgery in the Medicare population and relevant socioeconomic factors. Medicare billing and demographic data from 2015 to 2019 were combined with national National Provider Identifier (NPI) registry data to identify the average travel distance to reach a neurosurgeon as well as the number of neurosurgeons in each county. This was merged with U.S. Census data to capture 23 socioeconomic attributes. Moran's I statistic was calculated across counties. Socioeconomic variables were compared using ANOVA. Hotspots with the highest neurosurgeon access were predominantly located in the Mid-Atlantic region, central Texas, and southern Montana. Coldspots were found in the Great Plains, Midwest, and Southern Texas. There were statistically significant differences (p < 0.05) between high- and low-access counties, including: stroke prevalence, poverty, median household income, and total population density. There were no statistically significant differences in most races or ethnicities. Overall, there exist statistically significant clusters of decreased neurosurgery access within the United States, with varying sociodemographic characteristics between access hotspots and coldspots.
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Affiliation(s)
| | | | - Edward Liang
- Carle Illinois College of Medicine, Urbana, IL, USA
| | - Eunhae Yeo
- Carle Illinois College of Medicine, Urbana, IL, USA
| | | | - Anant Naik
- Carle Illinois College of Medicine, Urbana, IL, USA
| | - Paul M Arnold
- Carle Illinois College of Medicine, Urbana, IL, USA; Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL, USA
| | - Wael Hassaneen
- Carle Illinois College of Medicine, Urbana, IL, USA; Department of Neurosurgery, Carle Foundation Hospital, Urbana, IL, USA.
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Wiedermann CJ. Use of Hyperoncotic Human Albumin Solution in Severe Traumatic Brain Injury Revisited-A Narrative Review and Meta-Analysis. J Clin Med 2022; 11:jcm11092662. [PMID: 35566786 PMCID: PMC9099946 DOI: 10.3390/jcm11092662] [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: 04/05/2022] [Revised: 05/07/2022] [Accepted: 05/07/2022] [Indexed: 11/16/2022] Open
Abstract
A significant proportion of patients with a severe traumatic brain injury (TBI) have hypoalbuminemia and require fluid resuscitation. Intravenous fluids can have both favorable and unfavorable consequences because of the risk of hyperhydration and hypo- or hyperosmolar conditions, which may affect the outcome of a TBI. Fluid resuscitation with human albumin solution (HAS) corrects low serum albumin levels and aids in preserving euvolemia in non-brain-injured intensive care units and in perioperative patients. However, the use of HAS for TBI remains controversial. In patients with TBI, the infusion of hypooncotic (4%) HAS was associated with adverse outcomes. The side effects of 4% HAS and the safety and efficacy of hyperoncotic (20-25%) HAS used in the Lund concept of TBI treatment need further investigation. A nonsystematic review, including a meta-analysis of controlled clinical trials, was performed to evaluate hyperoncotic HAS in TBI treatment. For the meta-analysis, the MEDLINE and EMBASE Library databases, as well as journal contents and reference lists, were searched for pertinent articles up to March 2021. Four controlled clinical studies involving 320 patients were included. The first was a randomized trial. Among 165 patients treated with hyperoncotic HAS, according to the Lund concept, 24 (14.5%) died vs. 59 out of 155 control patients (38.1%). A Lund concept intervention using hyperoncotic HAS was associated with a significantly reduced mortality (p = 0.002). Evidence of the beneficial effects of fluid management with hyperoncotic HAS on mortality in patients with TBI is at a high risk of bias. Prospective randomized controlled trials are required, which could lead to changes in clinical practice recommendations for fluid management in patients with TBI.
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Affiliation(s)
- Christian J. Wiedermann
- Institute of General Practice and Public Health, Claudiana—College of Health Professions, 39100 Bolzano, Italy;
- Department of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, 6060 Hall in Tyrol, Austria
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11
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Zhi-Ling C, Qi L, Jun-Yong Y, Bang-Qing Y. The prevalence and risk factors of posttraumatic cerebral infarction in patients with traumatic brain injury: a systematic review and meta-analysis. Bioengineered 2022; 13:11706-11717. [PMID: 35521755 PMCID: PMC9275913 DOI: 10.1080/21655979.2022.2070999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Posttraumatic cerebral infarction (PTCI) is a serious complication of traumatic brain injury (TBI), and the prevalence and risk factors of PTCI in TBI patients are in dispute. We systematically searched the literature in the PubMed, Embase, and Cochrane library up to October 2021 to identify studies on the prevalence and risk factors of PTCI in patients with TBI. The quality of observational studies was assessed by the Newcastle-Ottawa scale tool. Random-effects model was conducted. The Higgins` I2 statistic was used to measure heterogeneity between trials. Moreover, sensitive analyses were conducted to assess whether the pooled result was credible and robust. Eleven studies (3696 total TBI patients) were included. The pooled prevalence of PTCI in TBI patients was 14% (95% CI, 0.11-0.17; I2 = 83.1%). Sensitive analyses showed that the pooled prevalence of PTCI was 13% (95% CI, 0.10-0.15; I2 = 69.2%) by omitting Su et al. The prevalence of PTCI was associated with a lower Glasgow Coma Scale (GCS) score (OR, 0.33; 95% CI, 0.14-0.77; I2 = 99.2%), pupillary dilation (OR, 4.73; 95% CI, 4.30-5.19; I2 = 85.6%), abnormal PT (OR, 1.16; 95% CI,1.05-2.47; I2 = 99.2%), hematoma location (OR, 1.16; 95% CI,1.05-2.47; I2 = 99.2%) and hematoma volume (OR, 1.16; 95% CI,1.05-2.47; I2 = 99.2%). Whereas hypotensive shock, duraplasty, cerebral herniation, and thrombocytopenia were not statistically associated with PTCI. Lower GCS, pupillary dilation, abnormal PT, hematoma location, and hematoma volume were risk factors for PTCI. Considering some limitations, the conclusion of our study should be interpreted with caution.
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Affiliation(s)
- Chen Zhi-Ling
- The 900th Hospital of the Chinese People`s Liberation Army Joint Logistic Support Force, Fuzhou, China
| | - Li Qi
- The 900th Hospital of the Chinese People`s Liberation Army Joint Logistic Support Force, Fuzhou, China
| | - Yang Jun-Yong
- The 900th Hospital of the Chinese People`s Liberation Army Joint Logistic Support Force, Fuzhou, China
| | - Yuan Bang-Qing
- The 900th Hospital of the Chinese People`s Liberation Army Joint Logistic Support Force, Fuzhou, China
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Long-term oncological outcomes after haemorrhagic apoplexy in pituitary adenoma managed operatively and non-operatively. Acta Neurochir (Wien) 2022; 164:1115-1123. [PMID: 35039959 DOI: 10.1007/s00701-022-05119-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/03/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Depending on severity of presentation, pituitary apoplexy can be managed with acute surgery or non-operatively. We aim to assess long-term tumour control, visual and endocrinological outcomes following pituitary apoplexy with special emphasis on patients treated non-operatively. METHODS Multicentre retrospective cohort study. All patients with symptomatic pituitary apoplexy were included. Patients were divided into 3 groups: group 1: surgery within 7 days; group 2: surgery 7 days-3 months; group 3: non-operative. Further intervention for oncological reasons during follow-up was the primary outcome. Secondary outcome measures included visual and endocrinological function at last follow-up. RESULTS One hundred sixty patients were identified with mean follow-up of 48 months (n = 61 group 1; n = 34 group 2; n = 64 group 3). Factors influencing decision for surgical treatment included visual acuity loss (OR: 2.50; 95% CI: 1.02-6.10), oculomotor nerve palsy (OR: 2.80; 95% CI: 1.08-7.25) and compression of chiasm on imaging (OR: 9.50; 95% CI: 2.06-43.73). Treatment for tumour progression/recurrence was required in 17%, 37% and 24% in groups 1, 2 and 3, respectively (p = 0.07). Urgent surgery (OR: 0.16; 95% CI: 0.04-0.59) and tumour regression on follow-up (OR: 0.04; 95% CI: 0.04-0.36) were independently associated with long-term tumour control. Visual and endocrinological outcomes were comparable between groups. CONCLUSION Urgent surgery is an independent predictor of long-term tumour control following pituitary apoplexy. However, 76% of patients who successfully complete 3 months of non-operative treatment may not require any intervention in the long term.
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Luostarinen T, Vehviläinen J, Lindfors M, Reinikainen M, Bendel S, Laitio R, Hoppu S, Ala-Kokko T, Skrifvars M, Raj R. Trends in mortality after intensive care of patients with traumatic brain injury in Finland from 2003 to 2019: a Finnish Intensive Care Consortium study. Acta Neurochir (Wien) 2022; 164:87-96. [PMID: 34725728 PMCID: PMC8761133 DOI: 10.1007/s00701-021-05034-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 10/16/2021] [Indexed: 11/28/2022]
Abstract
Background Several studies have suggested no change in the outcome of patients with traumatic brain injury (TBI) treated in intensive care units (ICUs). This is mainly due to the shift in TBI epidemiology toward older and sicker patients. In Finland, the share of the population aged 65 years and over has increased the most in Europe during the last decade. We aimed to assess changes in 12-month and hospital mortality of patients with TBI treated in the ICU in Finland. Methods We used a national benchmarking ICU database (Finnish Intensive Care Consortium) to study adult patients who had been treated for TBI in four tertiary ICUs in Finland during 2003–2019. We divided admission years into quartiles and used multivariable logistic regression analysis, adjusted for case-mix, to assess the association between admission year and mortality. Results A total of 4535 patients were included. Between 2003–2007 and 2016–2019, the patient median age increased from 54 to 62 years, the share of patients having significant comorbidity increased from 8 to 11%, and patients being dependent on help in activities of daily living increased from 7 to 15%. Unadjusted hospital and 12-month mortality decreased from 18 and 31% to 10% and 23%, respectively. After adjusting for case-mix, a reduction in odds of 12-month and hospital mortality was seen in patients with severe TBI, intracranial pressure monitored patients, and mechanically ventilated patients. Despite a reduction in hospital mortality, 12-month mortality remained unchanged in patients aged ≥ 70 years. Conclusion A change in the demographics of ICU-treated patients with TBI care is evident. The outcome of younger patients with severe TBI appears to improve, whereas long-term mortality of elderly patients with less severe TBI has not improved. This has ramifications for further efforts to improve TBI care, especially among the elderly. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-021-05034-4.
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Affiliation(s)
- Teemu Luostarinen
- Anaesthesiology and Intensive Care, Hyvinkää Hospital, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Juho Vehviläinen
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matias Lindfors
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital & University of Eastern Finland, Kuopio, Finland
| | - Stepani Bendel
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital & University of Eastern Finland, Kuopio, Finland
| | - Ruut Laitio
- Department of Perioperative Services, Intensive Care and Pain Management, Turku University Hospital & University of Turku, Turku, Finland
| | - Sanna Hoppu
- Department of Intensive Care and Emergency Medicine Services, Tampere University Hospital & University of Tampere, Tampere, Finland
| | - Tero Ala-Kokko
- Department of Intensive Care, Oulu University Hospital & University of Oulu, Oulu, Finland
| | - Markus Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Yun JH. Surgical Outcomes in Patients with Simultaneous Traumatic Brain and Torso Injuries in a Single Regional Trauma Center over a 5-Year Period. JOURNAL OF TRAUMA AND INJURY 2021. [DOI: 10.20408/jti.2021.0099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose The purpose of the study is to analyze the results of surgical treatment of patients with brain and torso injury for 5 years in a single regional trauma center. Methods We analyzed multiple trauma patients who underwent brain surgery and torso surgery for chest or abdominal injury simultaneously or sequentially among all 14,175 trauma patients who visited Dankook University Hospital Regional Trauma Center from January 2015 to December 2019. Results A total of 25 patients underwent brain surgery and chest or abdominal surgery, with an average age of 55.4 years, 17 men and eight women. As a result of surgical treatment, there were 14 patients who underwent the surgery on the same day (resuscitative surgery), of which five patients underwent surgery simultaneously, four patients underwent brain surgery first, and one patient underwent chest surgery first, four patients underwent abdominal surgery first. Among the 25 treated patients, the 10 patients died, which the cause of death was five severe brain injuries and four hemorrhagic shocks. Conclusions In multiple damaged patients require both torso surgery and head surgery, poor prognosis was associated with low initial Glasgow Coma Scale and high Injury Severity Score. On the other hand, patients had good prognosis when blood pressure was maintained and operation for traumatic brain injury was performed first. At the same time, patients who had operation on head and torso simultaneously had extremely low survival rates. This may be associated with secondary brain injury due to low perfusion pressure or continuous hypotension and the traumatic coagulopathy caused by massive bleeding.
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15
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Brainstem and Cortical Spreading Depolarization in a Closed Head Injury Rat Model. Int J Mol Sci 2021; 22:ijms222111642. [PMID: 34769073 PMCID: PMC8584184 DOI: 10.3390/ijms222111642] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/14/2021] [Accepted: 10/25/2021] [Indexed: 11/17/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death in young individuals, and is a major health concern that often leads to long-lasting complications. However, the electrophysiological events that occur immediately after traumatic brain injury, and may underlie impact outcomes, have not been fully elucidated. To investigate the electrophysiological events that immediately follow traumatic brain injury, a weight-drop model of traumatic brain injury was used in rats pre-implanted with epidural and intracerebral electrodes. Electrophysiological (near-direct current) recordings and simultaneous alternating current recordings of brain activity were started within seconds following impact. Cortical spreading depolarization (SD) and SD-induced spreading depression occurred in approximately 50% of mild and severe impacts. SD was recorded within three minutes after injury in either one or both brain hemispheres. Electrographic seizures were rare. While both TBI- and electrically induced SDs resulted in elevated oxidative stress, TBI-exposed brains showed a reduced antioxidant defense. In severe TBI, brainstem SD could be recorded in addition to cortical SD, but this did not lead to the death of the animals. Severe impact, however, led to immediate death in 24% of animals, and was electrocorticographically characterized by non-spreading depression (NSD) of activity followed by terminal SD in both cortex and brainstem.
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16
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Sewalt CA, Gravesteijn BY, Menon D, Lingsma HF, Maas AIR, Stocchetti N, Venema E, Lecky FE. Primary versus early secondary referral to a specialized neurotrauma center in patients with moderate/severe traumatic brain injury: a CENTER TBI study. Scand J Trauma Resusc Emerg Med 2021; 29:113. [PMID: 34348784 PMCID: PMC8340517 DOI: 10.1186/s13049-021-00930-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 07/27/2021] [Indexed: 11/23/2022] Open
Abstract
Background Prehospital care for patients with traumatic brain injury (TBI) varies with some emergency medical systems recommending direct transport of patients with moderate to severe TBI to hospitals with specialist neurotrauma care (SNCs). The aim of this study is to assess variation in levels of early secondary referral within European SNCs and to compare the outcomes of directly admitted and secondarily transferred patients. Methods Patients with moderate and severe TBI (Glasgow Coma Scale < 13) from the prospective European CENTER-TBI study were included in this study. All participating hospitals were specialist neuroscience centers. First, adjusted between-country differences were analysed using random effects logistic regression where early secondary referral was the dependent variable, and a random intercept for country was included. Second, the adjusted effect of early secondary referral on survival to hospital discharge and functional outcome [6 months Glasgow Outcome Scale Extended (GOSE)] was estimated using logistic and ordinal mixed effects models, respectively. Results A total of 1347 moderate/severe TBI patients from 53 SNCs in 18 European countries were included. Of these 1347 patients, 195 (14.5%) were admitted after early secondary referral. Secondarily referred moderate/severe TBI patients presented more often with a CT abnormality: mass lesion (52% vs. 34%), midline shift (54% vs. 36%) and acute subdural hematoma (77% vs. 65%). After adjusting for case-mix, there was a large European variation in early secondary referral, with a median OR of 1.69 between countries. Early secondary referral was not associated with functional outcome (adjusted OR 1.07, 95% CI 0.78–1.69), nor with survival at discharge (1.05, 0.58–1.90). Conclusions Across Europe, substantial practice variation exists in the proportion of secondarily referred TBI patients at SNCs that is not explained by case mix. Within SNCs early secondary referral does not seem to impact functional outcome and survival after stabilisation in a non-specialised hospital. Future research should identify which patients with TBI truly benefit from direct transportation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-021-00930-1.
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Affiliation(s)
- Charlie Aletta Sewalt
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.
| | - Benjamin Yaël Gravesteijn
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Anesthesiology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - David Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Hester Floor Lingsma
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Esmee Venema
- Department of Public Health, Erasmus MC Medical Center, Postbus 2040, 3000 CA, Rotterdam, The Netherlands.,Department of Neurology, Erasmus MC Medical Center, Rotterdam, The Netherlands
| | - Fiona E Lecky
- Center for Urgent and Emergency Care Research (CURE), Health Services Research Section, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Alkhaibary A, Alshalawi A, Althaqafi RMM, Alghuraybi AA, Basalamah A, Shammaa AM, Altalhy AA, Abdelrahman TM. Traumatic Brain Injury: A Perspective on the Silent Epidemic. Cureus 2021; 13:e15318. [PMID: 34221767 PMCID: PMC8238020 DOI: 10.7759/cureus.15318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Epidemiological data regarding the causes, patterns, severity, and outcomes of traumatic brain injury (TBI) are essential to plan for preventive strategies addressing this public health epidemic. The main aim of this study is to explore the patterns and causes of traumatic brain injury at two trauma centers. Methods: A retrospective cohort study was conducted using a pre-tested validated data collection sheet. Data were collected from the medical records and electronic database of patients who presented to the emergency department with head trauma. Variables including the mechanisms, patterns of the injury, accompanying injuries, level of consciousness, and hospitalization duration were investigated for any possible association. Results: A total of 269 patients (78% males, 22% females) who satisfied our study criteria were included in the final analysis. Motor vehicle collisions were the most common reason for traumatic brain injury (57.6%) followed by falls (28.3%). There was a statistically significant association observed between type of hemorrhage and Glasgow coma scale at initial presentation (P < 0.05). Conclusion: The most common cause of traumatic brain injury is motor vehicle collisions, followed by falls. The public should be made aware of the importance of using safety and precautionary measures to minimize the impact of traumatic brain injuries. Educational programs for neurotrauma prevention can be developed and utilized as a blueprint for local hospitals and officials in the country.
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Affiliation(s)
- Ali Alkhaibary
- Division of Neurosurgery, Department of Surgery, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Riyadh, SAU.,Neurosurgery, King Abdullah International Medical Research Center, Riyadh, SAU.,College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, SAU
| | | | | | | | - Ali Basalamah
- Department of Neurosurgery, King Saud University Medical City/King Khalid University Hospital, Riyadh, SAU
| | - Ahmed M Shammaa
- Department of Surgery, College of Medicine, Medical University of Warsaw, Warsaw, POL
| | - Ali A Altalhy
- Department of Neurosurgery, King Faisal Medical Complex, Taif, SAU
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18
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Prosser CJ, Edwards D, Boumara O, Fuller G, Holliman D, Lecky F. Bypassing the nearest emergency department for a more distant neurosurgical centre in traumatic brain injury patients. Br J Neurosurg 2020; 36:31-37. [PMID: 33322927 DOI: 10.1080/02688697.2020.1858026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE Major trauma triage within regional trauma networks (RTN) select patients with suspected TBI for bypass to specialist neuroscience centres (SNC), expediting neurosurgical care but may delay resuscitation. This comparative effectiveness study assessed the impact of this strategy on the risk adjusted hospital survival rates of patients confirmed to have intracranial injury on brain computed tomography (CT) scan. METHOD A retrospective cohort study was conducted using Trauma Audit and Research Network trauma registry data. Adult patients with a TBI on CT scan were included if they presented between June 2015 to February 2016 to SNCs or non-specialist acute hospitals (NSAH) in the North of England (South Cumbria, Lancashire and the North East Region). Patients were identified as having bypassed a nearer NSAH emergency department (ED) to a SNC using google maps. Their standardised excess survival rate was compared to TBI patients who received primary treatment at a NSAH. A multivariate logistic regression model predicting 30-day survival after TBI (Ps14n)1 was used to adjust for variation in casemix between cohorts. STUDY DESIGN AND RESULTS 355 patients met the study inclusion criteria, with 89/355 (25%) of TBI patients bypassing a nearer NSAH to a SNC, and 266/355 (75%) receiving primary treatment at an NSAH. The median severity of intracranial injury was equivalent (median Head Abbreviated Injury Scale 4 (IQR 4-5) in each group. There was no statistically significant difference in the standardised excess survival rate between the two cohorts; +6.15% for bypass (95% CI -1.24% to +13.55%) versus -1.12% for non-bypass (95% CI -4.51% to +2.25%). CONCLUSION AND FUTURE RESEARCH No statistically significant survival benefit was identified for TBI patients who bypassed the nearest ED to attend a SNC compared to those receiving treatment at the nearest NSAH, however a clinically significant 7% excess survival rate merits a larger study.
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Affiliation(s)
- Callum J Prosser
- Centre for Urgent and Emergency Care Research, University of Sheffield School of Health and Related Research, Sheffield, UK
| | - David Edwards
- Centre for Urgent and Emergency Care Research, University of Sheffield School of Health and Related Research, Sheffield, UK
| | - Omar Boumara
- Trauma Audit and Research Network, Clinical Science Building, Salford Royal Hospital, Salford, UK
| | - Gordon Fuller
- Centre for Urgent and Emergency Care Research, University of Sheffield School of Health and Related Research, Sheffield, UK
| | | | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, University of Sheffield School of Health and Related Research, Sheffield, UK.,Trauma Audit and Research Network, Clinical Science Building, Salford Royal Hospital, Salford, UK
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Outcomes in Critically Ill Patients With Traumatic Brain Injury: Ethnicity, Documentation, and Insurance Status. Crit Care Med 2020; 48:31-40. [PMID: 31567403 DOI: 10.1097/ccm.0000000000004043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Disparities in traumatic brain injury outcomes for ethnic minorities and the uninsured have previously been demonstrated; however, outcomes in undocumented immigrants have not been examined. We wanted to determine whether ethnicity, insurance, and documentation status served as risk factors for disparities in traumatic brain injury outcomes between undocumented immigrants and documented residents. DESIGN Retrospective study. SETTING Patients diagnosed with traumatic brain injury admitted to the surgical/trauma ICU at a level 1 trauma center serving a large immigrant population in New York City from 2009 to 2016. PATIENTS Four-hundred seventy-one traumatic brain injury patients requiring surgical/trauma ICU admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Undocumented immigrants constituted 29% of the population, were younger (39 vs 57 yr old, respectively; p < 0.0001), Hispanic (83%; p < 0.0001), and uninsured (87%; p < 0.0001). Falls resulted in the majority of traumatic brain injuries in the total population, however, undocumented immigrants were almost twice as likely to be assaulted (p = 0.0032). There was no difference in presence of midline shifts, Injury Severity Score, Glasgow Coma Score, hypotension, hypoxia, and pupillary reactions between undocumented immigrants and documented residents. Undocumented immigrants presented with significantly more effaced basilar cisterns (p = 0.0008). There was no difference in hospital care between undocumented immigrants and documented residents as determined by emergency department to surgical/trauma ICU transfer times (p = 0.967). Undocumented immigrants were more likely to be discharged home (53% vs 33%, respectively; p = 0.0009) and less likely to be sent to rehabilitation (25% vs 32%, respectively; p = 0.0009). After adjusting length of stay and mortality for covariates, undocumented immigrants had shorter length of stay (p < 0.05) and there was no difference in hospital mortality between undocumented immigrants and documented residents. CONCLUSIONS Undocumented immigrants with traumatic brain injuries were more likely to be younger, have shorter length of stay, and experience similar mortality rates to documented residents. Social economic status may play a role in events prior to hospitalization and likely does in disposition outcomes.
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Schizodimos T, Soulountsi V, Iasonidou C, Kapravelos N. An overview of management of intracranial hypertension in the intensive care unit. J Anesth 2020; 34:741-757. [PMID: 32440802 PMCID: PMC7241587 DOI: 10.1007/s00540-020-02795-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 05/09/2020] [Indexed: 12/29/2022]
Abstract
Intracranial hypertension (IH) is a clinical condition commonly encountered in the intensive care unit, which requires immediate treatment. The maintenance of normal intracranial pressure (ICP) and cerebral perfusion pressure in order to prevent secondary brain injury (SBI) is the central focus of management. SBI can be detected through clinical examination and invasive and non-invasive ICP monitoring. Progress in monitoring and understanding the pathophysiological mechanisms of IH allows the implementation of targeted interventions in order to improve the outcome of these patients. Initially, general prophylactic measures such as patient's head elevation, fever control, adequate analgesia and sedation depth should be applied immediately to all patients with suspected IH. Based on specific indications and conditions, surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering ICP. Hyperosmolar therapy (mannitol or hypertonic saline) represents the cornerstone of medical treatment of acute IH while hyperventilation should be limited to emergency management of life-threatening raised ICP. Therapeutic hypothermia could have a possible benefit on outcome. To control elevated ICP refractory to maximum standard medical and surgical treatment, at first, high-dose barbiturate administration and then decompressive craniectomy as a last step are recommended with unclear and probable benefit on outcomes, respectively. The therapeutic strategy should be based on a staircase approach and be individualized for each patient. Since most therapeutic interventions have an uncertain effect on neurological outcome and mortality, future research should focus on both studying the long-term benefits of current strategies and developing new ones.
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Affiliation(s)
- Theodoros Schizodimos
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece.
| | - Vasiliki Soulountsi
- 1st Department of Intensive Care Medicine, George Papanikolaou General Hospital, Thessaloniki, Greece
| | - Christina Iasonidou
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece
| | - Nikos Kapravelos
- 2nd Department of Intensive Care Medicine, George Papanikolaou General Hospital, G. Papanikolaou Avenue, 57010, Exochi, Thessaloniki, Greece
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Rajwani KM, Lavrador JP, Ansaripour A, Tolias CM. Which factors influence the decision to transfer patients with traumatic brain injury to a neurosurgery unit in a major trauma network? Br J Neurosurg 2020; 34:271-275. [PMID: 32212864 DOI: 10.1080/02688697.2020.1742289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objectives: Within the pan London Major Trauma System many patients with minor or non-life threatening traumatic brain injury (TBI) remain at their local hospital and are not transferred to a major trauma centre (MTC). Our aim was to identify factors that influence the decision to transfer patients with TBI to a neurosurgical centre.Methods: This is a single centre prospective cohort study of all patients with TBI referred to our neurosurgery unit from regional acute hospitals over a 4-month period (Sept 2016-Jan 2017). Our primary outcome was transferred to a neurosurgical centre. We identified the following factors that may predict decision to transfer: patient demographics, transfer distance, antithrombotic therapy and severity of TBI based on initial Glasgow Coma Scale (GCS) and Marshall CT score. A multivariable logistic regression analysis was performed.Results: A total of 339 patients were referred from regional hospitals with TBI and of these, 53 (15.6%) were transferred to our hospital. The mean age of patients referred was 70.6 years, 62.5% were men and 43% on antithrombotic drugs. Eighty-six percent of patients had mild TBI (GCS 13-15) on initial assessment and 79% had a Marshall CT score of 2. The adjusted analysis revealed only higher age, higher Marshall Score, the presence of chronic subdural haematoma (CSDH), the presence of contusion(s) and fracture(s) predicted transfer (p<.05). Subgroup analysis consistently showed a higher Marshall score predicted transfer (p<.05).Conclusions: In our cohort higher Marshall score consistently predicted transfer to our neurosurgical centre. Presenting GCS, transfer distance and antithrombotic therapy did not influence decision to transfer.
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22
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Barkley AS, Spece LJ, Barros LM, Bonow RH, Ravanpay A, Ellenbogen R, Huoy P, Thy T, Sothea S, Pak S, LoGerfo J, Lele AV. A mixed-methods needs assessment of traumatic brain injury care in a low- and middle-income country setting: building neurocritical care capacity at two major hospitals in Cambodia. J Neurosurg 2019; 134:244-250. [PMID: 31860819 PMCID: PMC7372920 DOI: 10.3171/2019.10.jns192118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The high global burden of traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). These settings also have the greatest disparity in the availability of surgical care in general and neurosurgical care in particular. Recent focus has been placed on alleviating this surgical disparity. However, most capacity assessments are purely quantitative, and few focus on concomitantly assessing the complex healthcare system needs required to care for these patients. The objective of the present study was to use both quantitative and qualitative assessment data to establish a comprehensive approach to inform capacity-development initiatives for TBI care at two hospitals in an LMIC, Cambodia. METHODS This mixed-methods study used 3 quantitative assessment tools: the World Health Organization Personnel, Infrastructure, Procedures, Equipment, Supplies (WHO PIPES) checklist, the neurosurgery-specific PIPES (NeuroPIPES) checklist, and the Neurocritical Care (NCC) checklist at two hospitals in Phnom Penh, Cambodia. Descriptive statistics were obtained for quantitative results. Qualitative semistructured interviews of physicians, nurses, and healthcare administrators were conducted by a single interviewer. Responses were analyzed using a thematic content analysis approach and coded to allow categorization under the PIPES framework. RESULTS Of 35 healthcare providers approached, 29 (82.9%) participated in the surveys, including 19 physicians (65.5%) and 10 nurses (34.5%). The majority had fewer than 5 years of experience (51.7%), were male (n = 26, 89.7%), and were younger than 40 years of age (n = 25, 86.2%). For both hospitals, WHO PIPES scores were lowest in the equipment category. However, using the NCC checklist, both hospitals scored higher in equipment (81.2% and 62.7%) and infrastructure (78.6% and 69.6%; hospital 1 and 2, respectively) categories and lowest in the training/continuing education category (41.7% and 33.3%, hospital 1 and 2, respectively). Using the PIPES framework, analysis of the qualitative data obtained from interviews revealed a need for continuing educational initiatives for staff, increased surgical and critical care supplies and equipment, and infrastructure development. The analysis further elucidated barriers to care, such as challenges with time availability for experienced providers to educate incoming healthcare professionals, issues surrounding prehospital care, maintenance of donated supplies, and patient poverty. CONCLUSIONS This mixed-methods study identified areas in supplies, equipment, and educational/training initiatives as areas for capacity development for TBI care in an LMIC such as Cambodia. This first application of the NCC checklist in an LMIC setting demonstrated limitations in its use in this setting. Concomitant qualitative assessments provided insight into barriers otherwise undetected in quantitative assessments.
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Affiliation(s)
| | - Laura J. Spece
- Department of Medicine, University of Washington
- Department of Health Services Research and Development, VA Puget Sound Health Care System, Seattle, Washington
| | | | - Robert H. Bonow
- Department of Neurological Surgery, University of Washington
| | - Ali Ravanpay
- Department of Neurological Surgery, University of Washington
- Department of Neurological Surgery, VA Puget Sound Health Care System, Seattle, Washington
| | | | - Phearum Huoy
- Department of Neurological Surgery, Khmer Soviet Friendship Hospital
| | - Try Thy
- Department of Neurological Surgery, University of Health Sciences, Phnom Penh, Cambodia
| | - Seang Sothea
- Department of Neurological Surgery, University of Health Sciences, Phnom Penh, Cambodia
| | - Sopheak Pak
- Technical Office, University of Health Sciences, Phnom Penh, Cambodia
| | - James LoGerfo
- Department of Medicine, Division of General Internal Medicine, University of Washington, Seattle, Washington
- Department of Global Health, University of Washington, Seattle, Washington
| | - Abhijit V. Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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Austin T. The development of neonatal neurointensive care. Pediatr Res 2019:10.1038/s41390-019-0729-5. [PMID: 31852010 DOI: 10.1038/s41390-019-0729-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 12/06/2019] [Accepted: 12/09/2019] [Indexed: 01/06/2023]
Abstract
Brain injury remains one of the major unsolved problems in neonatal care, with survivors at high risk of lifelong neurodisability. It is unlikely that a single intervention can ameliorate neonatal brain injury, given the complex interaction between pathological processes, developmental trajectory, genetic susceptibility, and environmental influences. However, a coordinated, interdisciplinary approach to understand the root cause enables early detection, and diagnosis with enhanced clinical care offering the best chance of improving outcomes and facilitate new lines of neuroprotective treatments. Adult neurointensive care has existed as a speciality in its own right for over 20 years; however, it is only recently that large prospective studies have demonstrated the benefit of this model of care. The 'Neuro-intensive Care Nursery' model originated at the University of California San Francisco in 2008, and since then a growing number of units worldwide have adopted this approach. As well as providing consistent coordinated care for infants from a multidisciplinary team, it provides opportunities for specialist education and training in neonatal neurology, neuromonitoring, neuroimaging and nursing. This review outlines the origins of brain-oriented care of the neonate and the development of the Neuro-NICU (neonatal intensive care unit) and discusses some of the challenges and opportunities in expanding this model of care.
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Affiliation(s)
- Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
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24
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Hutchison JS, Emery C, Gagnon I, Léger C, Riopelle R, Wellington C, Wilson E, Turgeon AF. The Canadian Traumatic Brain Injury Research Consortium: Epitomizing Collaborative Research in Canada. J Neurotrauma 2019; 35:1858-1863. [PMID: 30074867 DOI: 10.1089/neu.2018.5871] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death in the first half of life and a chronic disability for Canadians of all ages. Despite the recognized importance of TBI, there is no integrated national strategy for research and best practices in Canada. We therefore created the Canadian TBI Research Consortium (CTRC) to build an ideal model of collaboration between Canadian TBI researchers. Our objectives were to: (1) Create a collaborative Canadian research network, (2) improve patient survival, functional outcome, and health through sustainable and scalable evidence-based practice implementation, (3) strengthen the healthcare system for patients with TBI, (4) provide international leadership and collaboration in TBI research, (5) build stronger links with patients and their representatives to help set the research agenda, and to participate in analysis of its impacts, and (6) support current researchers and prepare the next generation of leaders in TBI research. Building on the highly successful 30-year history of the Canadian Critical Care Trials Group, we developed a highly collaborative research group that integrates the multi-disciplinary network of TBI researchers in Canada. The CTRC conducts multi-center clinically relevant practice changing research. Our research is developed around investigator-led project-based research using a programmatic approach and multiple methodologies. Through strong and sustainable career development and mentorship programs, we train and develop the next generation of TBI researchers. Our group is composed of more than 100 Canadian researchers from coast to coast, most of them funded by the Canadian Institutes of Health Research and other granting agencies. In conclusion, the CTRC prioritizes investigator-led TBI research and broadens the research agenda by integrating researchers from different disciplines in the field of TBI research to optimize delivery of care and improve the health of Canadians with TBI. Our goals are being accomplished across the whole continuum of care by conducting clinically relevant and practice-changing research.
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Affiliation(s)
- James S Hutchison
- 1 Department of Critical Care, The Hospital for Sick Children , Toronto, Ontario, Canada .,2 Neuroscience and Mental Health Research Program, The Hospital for Sick Children Research Institute , Toronto, Ontario, Canada .,3 Interdepartmental Division of Critical Care, The University of Toronto , Toronto, Ontario, Canada .,4 Institute of Medical Science, The University of Toronto , Toronto, Ontario, Canada
| | - Carolyn Emery
- 5 Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary , Calgary, Alberta, Canada .,6 Hotchkiss Brain Institute, Alberta Children's Hospital Research Institute, O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary , Calgary, Alberta, Canada
| | - Isabelle Gagnon
- 7 School of Physical and Occupational Therapy, McGill University , Montréal, Québec, Canada .,8 Trauma Center, Montreal Children's Hospital, McGill University Health Center , Montréal, Québec, Canada
| | - Caroline Léger
- 9 CHU de Québec - Université Laval Research Center , Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Québec City, Québec, Canada
| | - Richard Riopelle
- 10 Ontario Neurotrauma Foundation , Toronto, Ontario, Canada .,11 Brain Injury Canada , Ottawa, Ontario, Canada
| | - Cheryl Wellington
- 12 Department of Pathology and Laboratory Medicine, Djavad Mowafaghian Centre for Brain Health, University of British Columbia , Vancouver, British Columbia, Canada
| | - Elisa Wilson
- 2 Neuroscience and Mental Health Research Program, The Hospital for Sick Children Research Institute , Toronto, Ontario, Canada
| | - Alexis F Turgeon
- 9 CHU de Québec - Université Laval Research Center , Population Health and Optimal Health Practices Research Unit (Trauma - Emergency - Critical Care Medicine), Québec City, Québec, Canada .,13 Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval , Québec City, Québec, Canada
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Khellaf A, Khan DZ, Helmy A. Recent advances in traumatic brain injury. J Neurol 2019; 266:2878-2889. [PMID: 31563989 PMCID: PMC6803592 DOI: 10.1007/s00415-019-09541-4] [Citation(s) in RCA: 171] [Impact Index Per Article: 34.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 09/11/2019] [Accepted: 09/11/2019] [Indexed: 01/31/2023]
Abstract
Traumatic brain injury (TBI) is the most common cause of death and disability in those aged under 40 years in the UK. Higher rates of morbidity and mortality are seen in low-income and middle-income countries making it a global health challenge. There has been a secular trend towards reduced incidence of severe TBI in the first world, driven by public health interventions such as seatbelt legislation, helmet use, and workplace health and safety regulations. This has paralleled improved outcomes following TBI delivered in a large part by the widespread establishment of specialised neurointensive care. This update will focus on three key areas of advances in TBI management and research in moderate and severe TBI: refining neurointensive care protocolized therapies, the recent evidence base for decompressive craniectomy and novel pharmacological therapies. In each section, we review the developing evidence base as well as exploring future trajectories of TBI research.
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Affiliation(s)
- Abdelhakim Khellaf
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Box 167, Hills Road, Cambridge, CB2 0QQ, UK.,Faculty of Medicine, McGill University, Montreal, Canada
| | - Danyal Zaman Khan
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Box 167, Hills Road, Cambridge, CB2 0QQ, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Box 167, Hills Road, Cambridge, CB2 0QQ, UK.
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Ageron FX, Gayet-Ageron A, Steyerberg E, Bouzat P, Roberts I. Prognostic model for traumatic death due to bleeding: cross-sectional international study. BMJ Open 2019; 9:e026823. [PMID: 31142526 PMCID: PMC6549712 DOI: 10.1136/bmjopen-2018-026823] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To develop and validate a prognostic model and a simple model to predict death due to bleeding in trauma patients. DESIGN Cross-sectional study with multivariable logistic regression using data from two large trauma cohorts. SETTING 274 hospitals from 40 countries in the Clinical Randomisation of Anti-fibrinolytic in Significant Haemorrhage (CRASH-2) trial and 24 hospitals in the Northern French Alps Trauma registry. PARTICIPANTS 13 485 trauma patients in the CRASH-2 trial and 9945 patients in the Northern French Alps Trauma registry who were admitted to hospital within 3 hours of injury. MAIN OUTCOME MEASURE In-hospital death due to bleeding within 28 days. RESULTS There were 815 (6%) deaths from bleeding in the CRASH-2 trial and 102 (1%) in the Northern French Alps Trauma registry. The full model included age, systolic blood pressure (SBP), Glasgow Coma Scale (GCS), heart rate, respiratory rate and type of injury (penetrating). The simple model included age, SBP and GCS. In a cross-validation procedure by country, discrimination and calibration were adequate (pooled C-statistic 0.85 (95% CI 0.81 to 0.88) for the full model and 0.84 (95% CI 0.80 to 0.88) for the simple model). CONCLUSION This prognostic model can identify trauma patients at risk of death due to bleeding in a wide range of settings and can support prehospital triage and trauma audit, including audit of tranexamic acid use.
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Affiliation(s)
- Francois-Xavier Ageron
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
- Emergency Department and Northern French Alps Emergency Network, Hospital Annecy Genevois, Annecy, France
| | - Angele Gayet-Ageron
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
- Clinical Research Center and Division of Clinical Epidemiology, Department of Health and Community Medicine, University Hospital Geneva, Geneva, Switzerland
| | - Ewout Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Rotterdam, The Netherlands
- Department of Public Health, Erasmus MC, Rotterdam, The Netherlands
| | - Pierre Bouzat
- Grenoble Alpes Trauma Center, Pôle Anesthésie-Réanimation, CHU Grenoble Alpes, Grenoble, France
| | - Ian Roberts
- Clinical Trials Unit, London School of Hygiene & Tropical Medicine, London, UK
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Acute and Subacute Outcome Predictors in Moderate and Severe Traumatic Brain Injury: A Retrospective Monocentric Study. World Neurosurg 2019; 128:e531-e540. [PMID: 31048051 DOI: 10.1016/j.wneu.2019.04.190] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Revised: 04/20/2019] [Accepted: 04/22/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Prognostic factors affecting outcome of traumatic brain injury (TBI), despite their importance, are still under discussion. The purpose of this study was to describe risk factors of in-hospital mortality and outcome at 1 year in a homogeneously treated population of patients with moderate/severe TBI. METHODS A total of 193 consecutive patients with moderate or severe TBI (Glasgow Coma Scale [GCS] score 13-3, including patients with initial GCS score of 13 at high risk for subsequent neurologic deterioration), admitted to the intensive care unit, were retrospectively analyzed. In-hospital mortality and unfavorable outcome at 1 year, based on a Glasgow Outcome Scale-Extended score ≤4, were considered as primary and secondary outcomes. RESULTS At 1 year, unfavorable outcome occurred in 47.2%, including an in-hospital mortality of 19.7%. Increasing age, GCS motor score <3, coagulation disorders, and intracranial hypertension were acute risk factors of in-hospital mortality. In the 155 remaining survivors, Oxford Handicap Scale (OHS), posttraumatic cerebral infarction, cerebrospinal fluid disturbances, and length of intensive care unit stay were associated with unfavorable outcome at 1 year, in univariate analysis. A cutoff OHS score ≥3 discriminated the probability of an unfavorable outcome (area under the curve, 0.87; P < 0.001; specificity, 74%; sensitivity, 84%). Combining the effect of acute and subacute variables in a multivariate analysis, increasing age and OHS score were independent predictors of outcome. CONCLUSIONS The results of this retrospective study confirmed age as the main acute risk factor and identified OHS as new potential subacute predictor of unfavorable outcome in moderate and severe TBI.
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Martin M, Lobo D, Bitot V, Couffin S, Escalard S, Mounier R, Cook F. Prediction of Early Intracranial Hypertension After Severe Traumatic Brain Injury: A Prospective Study. World Neurosurg 2019; 127:e1242-e1248. [PMID: 31009774 DOI: 10.1016/j.wneu.2019.04.121] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 04/12/2019] [Accepted: 04/13/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This study aimed to assess the reliability of clinical features, noninvasive transcranial Doppler-related pulsatility index (PI) calculation, and optic nerve sheath diameter (ONSD) measured by ultrasound (US) and initial computed tomography (CT) scan (Marshall CT scan classification) in predicting the occurrence of early (<24 hours) high intracranial pressure (EHICP) (>20 mm Hg) after severe traumatic brain injury (TBI). METHODS We conducted an observational prospective study in a level 1 trauma center. Patients were measured simultaneously for PI and US ONSD in the triage zone. Patients were categorized into 2 groups: those who had EHICP after TBI (EHICP+) and those who did not (EHICP-). RESULTS Fifty-four patients were included; 32 were categorized as EHICP+ and 22 as EHICP-. PI >1.4 did not correlate with EHICP+ patients (69% vs. 46%, P = 0.09). US ONSD measurement was higher in the EHICP+ group (6.25; range, 6-6.95 vs. 5.7; range, 5.2-6.4; P = 0.005). The area under the receiver operating characteristic curve for US ONSD as a predictor of developing EHICP was 0.73 (95% confidence interval [CI], 0.59-0.86). CT ONSD measurement was higher in the EHICP+ group (6.71; range, 6.35-7.87 vs. 6.25; range, 5.8-6.93; P = 0.04). The area under the receiver operating characteristic curve for CT ONSD measurement as a predictor for EHICP+ was 0.67 (95% CI, 0.53-0.81). The diffuse injury III and IV categories in the Marshall CT scan classification were associated with the occurrence of EHICP (P = 0.004). CONCLUSIONS None of the clinical features or noninvasive tools assessed in this study enabled clinicians to strictly ascertain EHICP. Further studies are needed to establish their potential role before intracranial pressure probe insertion.
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Affiliation(s)
- Mathieu Martin
- Department of Anaesthesiology and Critical Care Medicine, Surgical Intensive Care Unit - Trauma Center, Créteil, France.
| | - David Lobo
- Department of Anaesthesiology and Critical Care Medicine, Surgical Intensive Care Unit - Trauma Center, Créteil, France
| | - Valérie Bitot
- Department of Anaesthesiology and Critical Care Medicine, Surgical Intensive Care Unit - Trauma Center, Créteil, France
| | - Séverine Couffin
- Department of Anaesthesiology and Critical Care Medicine, Surgical Intensive Care Unit - Trauma Center, Créteil, France
| | - Simon Escalard
- Department of Neuroradiology, Paris-Est Créteil University and Assistance-Publique Hôpitaux de Paris, Henri Mondor University Hospital, Créteil, France
| | - Roman Mounier
- Department of Anaesthesiology and Critical Care Medicine, Surgical Intensive Care Unit - Trauma Center, Créteil, France
| | - Fabrice Cook
- Department of Anaesthesiology and Critical Care Medicine, Surgical Intensive Care Unit - Trauma Center, Créteil, France
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Sidek MSM, Siregar JA, Ghani ARI, Idris Z. Teleneurosurgery: Outcome of Mild Head Injury Patients Managed in Non-Neurosurgical Centre in the State of Johor. Malays J Med Sci 2019; 25:95-104. [PMID: 30918459 PMCID: PMC6422582 DOI: 10.21315/mjms2018.25.2.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 02/22/2018] [Indexed: 10/28/2022] Open
Abstract
Background With teleneurosurgery, more patients with head injury are managed in the primary hospital under the care of general surgical unit. Growing concerns regarding the safety and outcome of these patients are valid and need to be addressed. Method This study is to evaluate the outcome of patients with mild head injury which were managed in non-neurosurgical centres with the help of teleneurosurgery. The study recruits samples from five primary hospitals utilising teleneurosurgery for neurosurgical consultations in managing mild head injury cases in Johor state. Two main outcomes were noted; favourable and unfavourable, with a follow up review of the Glasgow Outcome Scale (GOS) at 3 and 6 months. Results Total of 359 samples were recruited with a total of 11 (3.06%) patients have an unfavourable. no significant difference in GOS at 3 and 6 months for patient in the unfavourable group (P = 0.368). Conclusion In this study we have found no significant factors affecting the outcome of mild head injury patients managed in non-neurosurgical centres in Johor state using the help of teleneurosurgery.
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Affiliation(s)
- Mohd Syahiran Mohd Sidek
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.,Department of Neurosurgery, Hospital Sultanah Aminah Johor Bahru, 80100 JohorBharu, Malaysia
| | - Johari Adnan Siregar
- Department of Neurosurgery, Hospital Kuala Lumpur, 50586, Wilayah Persekutuan Kuala Lumpur, Malaysia
| | - Abdul Rahman Izani Ghani
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.,Center for Neuroscience Services and Research, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
| | - Zamzuri Idris
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia.,Center for Neuroscience Services and Research, Universiti Sains Malaysia, 16150 Kubang Kerian, Kelantan, Malaysia
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Barrett JW. A retrospective review of patients with significant traumatic brain injury transported by emergency medical services within the south east of England. Br Paramed J 2019; 3:1-7. [PMID: 33328810 PMCID: PMC7706740 DOI: 10.29045/14784726.2019.03.3.4.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: Traumatic brain injury (TBI) will be a leading cause of death and disability within the Western world by 2020. Currently, 80% of all TBI patients in England are transported to hospital by an ambulance service. The aim of this retrospective study is to compare TBI patients transported to a major trauma centre (MTC) against those transported to a trauma unit (TU). Method: All patients with a primary injury of TBI who were transported to hospital by South East Coast Ambulance Service NHS Foundation Trust (SECAmb) from 1 January 2016 to 31 December 2016 and entered into the Trauma Audit & Research Network (TARN) registry were reviewed. Patients were stratified by hospital designation (MTC or TU). Severity of TBI was categorised using the patients’ pre-hospital Glasgow Coma Scale (GCS) and Abbreviated Injury Score (AIS) Head. The outcomes of interest were 30-day mortality and Glasgow Outcome Score (GOS) at discharge. Results: Between 1 January and 31 December 2016, 549 TBI patients were identified in the TARN database as being transported by SECAmb to either an MTC or a TU. The majority of patients were transported to a TU (77.96%), and the median age of the TU cohort was older than the MTC group (TU 82.15 IQR 16.73 vs. MTC 62.1 IQR 42.6). The median Injury Severity Score (ISS) was greater in the MTC cohort (22 IQR 10 vs. 17 IQR 9), where falls from height and road traffic collisions (RTCs) contributed to 50.51% of all injuries. Within the TU cohort, falls from less than 2 metres (standing height) were the main mechanism of injury (MOI) (77.62%). The median length of hospital stay (LOS) was longer in the MTC cohort compared to the TU cohort (10 IQR 13.25 vs. 8 IQR 14). Conclusion: The high proportion of mild TBI and absence of reliable triage guidelines make it difficult for ambulance clinicians to identify patients who will benefit from transport to an MTC. Future research should focus on how TBI triage influences outcomes and how ambulance services can better identify patients with a TBI and who would benefit from specialist care.
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Stocker RA. Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection. Med Sci (Basel) 2019; 7:medsci7030037. [PMID: 30813644 PMCID: PMC6473302 DOI: 10.3390/medsci7030037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.
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Affiliation(s)
- Reto A Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, CH-8032 Zurich, Switzerland.
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Quinn P, Walton B, Lockey D. An observational study evaluating the demand of major trauma on different surgical specialities in a UK Major Trauma Centre. Eur J Trauma Emerg Surg 2019; 46:1137-1142. [PMID: 30661136 DOI: 10.1007/s00068-019-01075-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 01/03/2019] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Major Trauma Centres (MTCs) should ideally have all key surgical specialities on site. This may not always be the case since trauma is only one factor influencing speciality location. The implications of this can only be understood when the demands on specific specialities are established and this is not well documented. We investigated surgical speciality demand by quantifying the frequency and urgency of surgical trauma interventions. PATIENTS AND METHODS Data on adult trauma admissions for a UK MTC were retrieved from the UK Trauma Audit and Research Network for a 2-year period and analysed to establish the frequency and urgency of surgical interventions. RESULTS Of 1285 trauma patients with an ISS > 15 presenting in the study year period 713 (55.5%) required surgery. Neurosurgical (59.9%) and orthopaedic (55.1%) operations were most frequent. Cardiothoracic, general surgery, plastic surgery and maxillofacial operations were required infrequently. General surgery was commonly needed urgently, 45% within 4 h of MTC arrival. Urgency was also common in interventional radiology and vascular surgery. Cardiothoracic interventions were mainly urgent interventions (thoracotomy 1/3) and less urgent (rib fixation 2/3). DISCUSSION Neurosurgery and orthopaedic surgery are key on-site trauma specialities and required frequently. General surgery, interventional radiology and cardiothoracic interventions are required less frequently but often urgently. This confirms a need for MTC on-site capability and possibly training to maintain competency in occasional trauma operators, particularly in general surgery. Maxillofacial surgery, ENT and urology are required neither frequently nor urgently and on-site presence may be less critical. CONCLUSION Demand for specific surgical specialities was reported in a cohort of UK trauma patients. This confirmed the need for rapid on-site capability in key specialities and highlights possible training requirements for occasional trauma operators in specialities with low frequency but high urgency.
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Affiliation(s)
| | | | - David Lockey
- University of Bristol, Bristol, UK.
- North Bristol NHS Trust, Bristol, UK.
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Final outcome trends in severe traumatic brain injury: a 25-year analysis of single center data. Acta Neurochir (Wien) 2018; 160:2291-2302. [PMID: 30377831 DOI: 10.1007/s00701-018-3705-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 10/16/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Evidence from the last 25 years indicates a modest reduction of mortality after severe traumatic head injury (sTBI). This study evaluates the variation over time of the whole Glasgow Outcome Scale (GOS) throughout those years. METHODS The study is an observational cohort study of adults (≥ 15 years old) with closed sTBI (GCS ≤ 8) who were admitted within 48 h after injury. The final outcome was the 1-year GOS, which was divided as follows: (1) dead/vegetative, (2) severely disabled (dependent patients), and (3) good/moderate recovery (independent patients). Patients were treated uniformly according to international protocols in a dedicated ICU. We considered patient characteristics that were previously identified as important predictors and could be determined easily and reliably. The admission years were divided into three intervals (1987-1995, 1996-2004, and 2005-2012), and the following individual CT characteristics were noted: the presence of traumatic subarachnoid or intraventricular hemorrhage (tSAH, IVH), midline shift, cisternal status, and the volume of mass lesions (A × B × C/2). Ordinal logistic regression was performed to estimate associations between predictors and outcomes. The patients' estimated propensity scores were included as an independent variable in the ordinal logistic regression model (TWANG R package). FINDINGS The variables associated with the outcome were age, pupils, motor score, deterioration, shock, hypoxia, cistern status, IVH, tSAH, and epidural volume. When adjusting for those variables and the propensity score, we found a reduction in mortality from 55% (1987-1995) to 38% (2005-2012), but we discovered an increase in dependent patients from 10 to 21% and just a modest increase in independent patients of 6%. CONCLUSIONS This study covers 25 years of management of sTBI in a single neurosurgical center. The prognostic factors are similar to those in the literature. The improvement in mortality does not translate to better quality of life.
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Siebold L, Obenaus A, Goyal R. Criteria to define mild, moderate, and severe traumatic brain injury in the mouse controlled cortical impact model. Exp Neurol 2018; 310:48-57. [DOI: 10.1016/j.expneurol.2018.07.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 06/05/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
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Hsieh CH, Chen YC, Hsu SY, Hsieh HY, Chien PC. Defining polytrauma by abbreviated injury scale ≥ 3 for a least two body regions is insufficient in terms of short-term outcome: A cross-sectional study at a level I trauma center. Biomed J 2018; 41:321-327. [PMID: 30580796 PMCID: PMC6306305 DOI: 10.1016/j.bj.2018.08.007] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 08/01/2018] [Accepted: 08/15/2018] [Indexed: 11/26/2022] Open
Abstract
Background Patients with polytrauma are expected to have a higher risk of mortality than the summation of expected mortality for their individual injuries. This study was designed to investigate the outcome of polytrauma patients, diagnosed by abbreviated injury scale (AIS) ≥ 3 for at least two body regions, at a level I trauma center. Methods Detailed data of 694 polytrauma patients and 2104 non-polytrauma patients with an overall Injury Severity Score (ISS) ≥ 16 and hospitalized between January 1, 2009, and December 31, 2014 for treatment of all traumatic injuries, were retrieved from the Trauma Registry System. Two-sided Fisher exact or Pearson chi-square tests were used to compare categorical data. The unpaired Student t-test was used to analyze normally distributed continuous data, and the Mann–Whitney U-test was used to compare non-normally distributed data. Propensity-score matching in a 1:1 ratio was performed using NCSS software with logistic regression to evaluate the effect of polytrauma on in-hospital mortality. Results There was no significant difference in short-term mortality between polytrauma and non-polytrauma patients, regardless of whether the comparison was made among the total patients (11.4% vs. 11.0%, respectively; p = 0.795) or among the selected propensity score-matched groups of patients following controlled covariates including sex, age, systolic blood pressure, co-morbidities, Glasgow Coma Scale scores, injury region based on AIS. Conclusions Polytrauma defined by AIS ≥3 for at least two body regions failed to recognize a significant difference in short-term mortality among trauma patients.
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Affiliation(s)
- Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan.
| | - Yi-Chun Chen
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Shiun-Yuan Hsu
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
| | - Peng-Chen Chien
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taiwan
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Lindfors M, Vehviläinen J, Siironen J, Kivisaari R, Skrifvars MB, Raj R. Temporal changes in outcome following intensive care unit treatment after traumatic brain injury: a 17-year experience in a large academic neurosurgical centre. Acta Neurochir (Wien) 2018; 160:2107-2115. [PMID: 30191364 DOI: 10.1007/s00701-018-3670-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Accepted: 08/31/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of morbidity and mortality. However, it remains undetermined whether long-term outcomes after TBI have improved over the past two decades. METHODS We conducted a retrospective analysis of consecutive TBI patients admitted to an academic neurosurgical ICU during 1999-2015. Primary outcomes of interest were 6-month all-cause mortality (available for all patients) and 6-month Glasgow Outcome Scale (GOS, available from 2005 onwards). GOS was dichotomized to favourable and unfavourable functional outcome. Temporal changes in outcome were assessed using multivariate logistic regression analysis, adjusting for age, sex, GCS motor score, pupillary light responsiveness, Marshall CT classification and major extracranial injury. RESULTS Altogether, 3193 patients were included. During the study period, patient age and admission Glasgow Coma Scale score increased, while the overall TBI severity did not change. Overall unadjusted 6-month mortality was 25% and overall unadjusted unfavourable outcome (2005-2015) was 44%. There was no reduction in the adjusted odds of 6-month mortality (OR 0.98; 95% CI 0.96-1.00), but the adjusted odds of favourable functional outcome significantly increased (OR 1.08; 95% CI 1.04-1.11). Subgroup analysis showed outcome improvements only in specific subgroups (conservatively treated patients, moderate-to-severe TBI patients, middle-aged patients). CONCLUSIONS During the past two decades, mortality after significant TBI has remained largely unchanged, but the odds of favourable functional outcome have increased significantly in specific subgroups, implying an improvement in quality of care. These developments have been paralleled by notable changes in patient characteristics, emphasizing the importance of continuous epidemiological monitoring.
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Bierbaum M, Lystad RP, Curtis K, Mitchell R. Incidence and severity of head injury hospitalisations in Australian children over a 10-year period. Health Promot J Austr 2018; 30:189-198. [PMID: 30030878 DOI: 10.1002/hpja.186] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 05/18/2018] [Accepted: 07/13/2018] [Indexed: 11/05/2022] Open
Abstract
ISSUE ADDRESSED Child head injuries can cause life-long disability and are a major cause of mortality globally. The incidence and impact of child head injuries in Australia is unknown. This study aimed to quantify the incidence, characteristics and treatment cost and to identify factors associated with the severity of hospitalisations of head injuries in Australian children. METHODS Linked hospitalisation and mortality data were used to retrospectively examine hospitalisation trends for head injury in children aged ≤16 years and associated factors, in Australia, from 1 July 2002 to 30 June 2012. RESULTS There were 164 126 hospitalisations of children for head injury during the 10-year period, commonly male (65.5%), or aged ≤5 years (48.3%). The incidence among children aged <1 year and 1-5 years significantly increased by 1.7% (95% CI 0.9-2.6; P < 0.0001) and 1.5% (95% CI 1.1-1.9; P < 0.0001) annually during the study period, respectively. The most common injury mechanisms across all age groups were falls (45.2%) and road trauma (16.0%). Head injury hospitalisations cost $468.9 million, with the higher costs found for children aged 11-16 years, and for the most severe injuries. CONCLUSION Head injury hospitalisations cost the Australian health system close to half a billion dollars over a 10-year period, with the most serious injuries resulting in lifelong health implications. SO WHAT?: Targeted health promotion strategies such as the promotion of helmet wearing during scooter use, the introduction of cycleways, and impact absorbing surfaces on playgrounds, need to be implemented to reduce the occurrence of head injuries in children.
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Affiliation(s)
- Mia Bierbaum
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Reidar P Lystad
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Kate Curtis
- Sydney Nursing School, The University of Sydney, Sydney, New South Wales, Australia
| | - Rebecca Mitchell
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
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Watanabe T, Kawai Y, Iwamura A, Maegawa N, Fukushima H, Okuchi K. Outcomes after Traumatic Brain Injury with Concomitant Severe Extracranial Injuries. Neurol Med Chir (Tokyo) 2018; 58:393-399. [PMID: 30101808 PMCID: PMC6156128 DOI: 10.2176/nmc.oa.2018-0116] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of death and disability in trauma patients. Patients with TBI frequently sustain concomitant injuries in extracranial regions. The effect of severe extracranial injury (SEI) on the outcome of TBI is controversial. For 8 years, we retrospectively enrolled 485 patients with the blunt head injury with head abbreviated injury scale (AIS) ≧ 3. SEI was defined as AIS ≧ 3 injuries in the face, chest, abdomen, and pelvis/extremities. Vital signs and coagulation parameter values were also extracted from the database. Total patients were dichotomized into isolated TBI (n = 343) and TBI associated with SEI (n = 142). The differences in severity and outcome between these two groups were analyzed. To assess the relation between outcome and any variables showing significant differences in univariate analysis, we included the parameters in univariable and multivariable logistic regression analyses. Mortality was 17.8% in the isolated TBI group and 21.8% in TBI with SEI group (P = 0.38), but the Glasgow Outcome Scale (GOS) in the TBI with SEI group was unfavorable compared to the isolated TBI group (P = 0.002). Patients with SBP ≦ 90 mmHg were frequent in the TBI with SEI group. Adjusting for age, GCS, and length of hospital stay, SEI was a strong prognostic factor for mortality with adjusted ORs of 2.30. Hypotension and coagulopathy caused by SEI are considerable factors underlying the secondary insults to TBI. It is important to manage not only the brain but the whole body in the treatment of TBI patients with SEI.
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Affiliation(s)
- Tomoo Watanabe
- Department of Emergency and Critical Care, Nara Medical University
| | - Yasuyuki Kawai
- Department of Emergency and Critical Care, Nara Medical University
| | - Asami Iwamura
- Department of Emergency and Critical Care, Nara Medical University
| | - Naoki Maegawa
- Department of Emergency and Critical Care, Nara Medical University
| | | | - Kazuo Okuchi
- Department of Emergency and Critical Care, Nara Medical University
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Association of Posttraumatic Stress Symptom Severity With Health-Related Quality of Life and Self-Reported Functioning Across 12 Months After Severe Traumatic Brain Injury. Arch Phys Med Rehabil 2018; 99:1576-1583. [DOI: 10.1016/j.apmr.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 02/05/2018] [Accepted: 02/10/2018] [Indexed: 11/15/2022]
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Huijben JA, Volovici V, Cnossen MC, Haitsma IK, Stocchetti N, Maas AIR, Menon DK, Ercole A, Citerio G, Nelson D, Polinder S, Steyerberg EW, Lingsma HF, van der Jagt M. Variation in general supportive and preventive intensive care management of traumatic brain injury: a survey in 66 neurotrauma centers participating in the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:90. [PMID: 29650049 PMCID: PMC5898014 DOI: 10.1186/s13054-018-2000-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/19/2018] [Indexed: 12/20/2022]
Abstract
Background General supportive and preventive measures in the intensive care management of traumatic brain injury (TBI) aim to prevent or limit secondary brain injury and optimize recovery. The aim of this survey was to assess and quantify variation in perceptions on intensive care unit (ICU) management of patients with TBI in European neurotrauma centers. Methods We performed a survey as part of the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study. We analyzed 23 questions focused on: 1) circulatory and respiratory management; 2) fever control; 3) use of corticosteroids; 4) nutrition and glucose management; and 5) seizure prophylaxis and treatment. Results The survey was completed predominantly by intensivists (n = 33, 50%) and neurosurgeons (n = 23, 35%) from 66 centers (97% response rate). The most common cerebral perfusion pressure (CPP) target was > 60 mmHg (n = 39, 60%) and/or an individualized target (n = 25, 38%). To support CPP, crystalloid fluid loading (n = 60, 91%) was generally preferred over albumin (n = 15, 23%), and vasopressors (n = 63, 96%) over inotropes (n = 29, 44%). The most commonly reported target of partial pressure of carbon dioxide in arterial blood (PaCO2) was 36–40 mmHg (4.8–5.3 kPa) in case of controlled intracranial pressure (ICP) < 20 mmHg (n = 45, 69%) and PaCO2 target of 30–35 mmHg (4–4.7 kPa) in case of raised ICP (n = 40, 62%). Almost all respondents indicated to generally treat fever (n = 65, 98%) with paracetamol (n = 61, 92%) and/or external cooling (n = 49, 74%). Conventional glucose management (n = 43, 66%) was preferred over tight glycemic control (n = 18, 28%). More than half of the respondents indicated to aim for full caloric replacement within 7 days (n = 43, 66%) using enteral nutrition (n = 60, 92%). Indications for and duration of seizure prophylaxis varied, and levetiracetam was mostly reported as the agent of choice for both seizure prophylaxis (n = 32, 49%) and treatment (n = 40, 61%). Conclusions Practice preferences vary substantially regarding general supportive and preventive measures in TBI patients at ICUs of European neurotrauma centers. These results provide an opportunity for future comparative effectiveness research, since a more evidence-based uniformity in good practices in general ICU management could have a major impact on TBI outcome. Electronic supplementary material The online version of this article (10.1186/s13054-018-2000-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jilske A Huijben
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Victor Volovici
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Neurosurgery, Office H-703, Erasmus MC Stroke Center and Brain Tumor Center, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Maryse C Cnossen
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Iain K Haitsma
- Department of Neurosurgery, Office H-703, Erasmus MC Stroke Center and Brain Tumor Center, Erasmus Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy.,Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Department of Anesthesia and Critical Care, Neuroscience Intensive Care Unit, Milan, Italy
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Suzanne Polinder
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Hester F Lingsma
- Center for Medical Decision Making, Department of Public Health, Erasmus Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care and Erasmus MC Stroke Center, Erasmus Medical Center, Rotterdam, the Netherlands
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De Vloo P, Nijs S, Verelst S, van Loon J, Depreitere B. Prehospital and Intrahospital Temporal Intervals in Patients Requiring Emergent Trauma Craniotomy. A 6-Year Observational Study in a Level 1 Trauma Center. World Neurosurg 2018; 114:e546-e558. [PMID: 29548947 DOI: 10.1016/j.wneu.2018.03.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 03/02/2018] [Accepted: 03/05/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE According to level 2 evidence, earlier evacuation of acute subdural or epidural hematomas necessitating surgery is associated with better outcome. Hence, guidelines recommend performing these procedures immediately. Literature on the extent and causes of prehospital and intrahospital intervals in patients with trauma requiring emergent craniotomies is almost completely lacking. Studies delineating and refining the interval before thrombolytic agent administration in ischemic stroke have dramatically reduced the door-to-needle time. A similar exercise for trauma-to-decompression time might result in comparable reductions. We aim to map intervals in emergent trauma craniotomies in our level 1 trauma center, screen for associated factors, and propose possible ways to reduce these intervals. METHODS We analyzed patients who were primarily referred (1R; n = 45) and secondarily referred (after computed tomography imaging in a community hospital [2R; n = 22]) to our emergency department (ED) and underwent emergent trauma craniotomies between 2010 and 2016. RESULTS Median prehospital interval (between emergency call and arrival at the ED) was 42 minutes for 1R patients. Median intrahospital interval (between initial ED arrival and skin incision [SI]) was 140 minutes and 268 minutes for 1R and 2R patients, respectively. In 1R patients, ED-SI interval was positively correlated with Glasgow Coma Scale score (ρ=.49; P < 0.001), but not with age, time of ED arrival, or extended Glasgow Outcome Scale score at 6 months. Based on outlier analysis, we propose prehospital and intrahospital measures to improve performance. CONCLUSIONS This is the first report on emergency call-SI interval in emergent trauma craniotomy, with a median of 174 minutes and >297 minutes for 1R and 2R patients, respectively, in our center.
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Affiliation(s)
- Philippe De Vloo
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium.
| | - Stefaan Nijs
- Department of Traumatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Sandra Verelst
- Department of Emergency Medicine, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Johannes van Loon
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
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The Evolution of Trauma in Los Angeles County Over More Than a Decade. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 25:E17-E20. [PMID: 29494413 DOI: 10.1097/phh.0000000000000745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Explore trends in trauma incidence and mortality rates in Los Angeles County. DESIGN Data for patients treated at Los Angeles County trauma centers from 2000 to 2011 were analyzed for this study. Age-adjusted incidence and mortality rates were calculated by gender, race, injury type, injury severity, and mechanism of injury. Trends were assessed using linear regression to determine the annual percentage change (APC). RESULTS There were 223 773 patients included. The trauma incidence rate increased by 14.6% driven by an increase in blunt injury of 5.4% annually (P < .05). Penetrating injury decreased at -6.9% APC (P < .01). Mortality rate decreased at -11.5% APC (P < .01), with reduction in both blunt (-6.8% APC [P < .01]) and penetrating injuries (-16.7% APC [P < .01]). The trends in mortality persisted with stratification by age, gender, race, and injury severity score. CONCLUSION In this mature trauma system, the trauma incidence increased slightly from 2000 to 2011, while the mortality steadily declined. Public health officials in other areas could perform a similar self-evaluation to describe and monitor injury events and trends in their jurisdictions, a reassessment of priority and trauma system resource allocation, which will directly benefit the regional population.
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Beck B, Gantner D, Cameron PA, Braaf S, Saxena M, Cooper DJ, Gabbe BJ. Temporal Trends in Functional Outcomes after Severe Traumatic Brain Injury: 2006-2015. J Neurotrauma 2018; 35:1021-1029. [PMID: 29256832 DOI: 10.1089/neu.2017.5287] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Severe traumatic brain injury (TBI) is associated with poor outcomes; however, little is known about whether these outcomes are improving over time. This study examined temporal trends in functional outcomes of severe TBI at six months post-injury. We conducted a retrospective cohort study (January 1, 2006 to December 31, 2015) of hospitalized adult (≥16 years) patients with severe TBI using data from the population-based Victorian State Trauma Registry. The primary outcome was the Glasgow Outcome Scale-Extended (GOS-E) at six months post-injury, dichotomized as upper severe disability or worse (GOS-E ≤4, termed "unfavorable outcome") and lower moderate disability or better (GOS-E ≥5; termed "favorable outcome"). Multivariable logistic regression was used to investigate temporal trends in functional outcomes at six months post-injury. Of the 1966 patients with severe TBI who were followed up at six months post-injury (median age, 42 years (interquartile range [IQR]: 25-68); male, 73%), a majority of patients had an unfavorable outcome (GOS-E ≤4; n = 1372, 70%). After adjusting for confounders, there was no change in functional outcomes over time (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI]: 0.98,1.06; p = 0.35). Similarly, there was no change in the adjusted odds of death (GOS-E = 1) at six months post-injury (AOR = 1.04, 95% CI: 1.00,1.08; p = 0.08). Using a population-wide, high quality, comprehensive registry, we demonstrated no change in death or functional outcomes after severe TBI between 2006 and 2015 in a mature trauma system. There is a clear need to identify targeted improvements in the treatment of these patients with the aim of reducing in-hospital death and improving long-term outcomes.
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Affiliation(s)
- Ben Beck
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia
| | - Dashiell Gantner
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,3 Department of Intensive Care and Hyperbaric Medicine, The Alfred , Melbourne, Victoria, Australia
| | - Peter A Cameron
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,4 Emergency and Trauma Centre, The Alfred Hospital , Melbourne, Victoria, Australia
| | - Sandra Braaf
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia
| | - Manoj Saxena
- 5 Intensive Care Unit, St George Hospital , Sydney, New South Wales, Australia .,6 Critical Care & Trauma Division, The George Institute for Global Health , University of New South Wales, Sydney, New South Wales, Australia
| | - D James Cooper
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,3 Department of Intensive Care and Hyperbaric Medicine, The Alfred , Melbourne, Victoria, Australia
| | - Belinda J Gabbe
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,7 Farr Institute, Swansea University Medical School, Swansea University , Swansea, United Kingdom
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Multimodality neuromonitoring in severe pediatric traumatic brain injury. Pediatr Res 2018; 83:41-49. [PMID: 29084196 DOI: 10.1038/pr.2017.215] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/31/2017] [Indexed: 12/18/2022]
Abstract
Each year, the annual hospitalization rates of traumatic brain injury (TBI) in children in the United States are 57.7 per 100K in the <5 years of age and 23.1 per 100K in the 5-14 years age group. Despite this, little is known about the pathophysiology of TBI in children and how to manage it most effectively. Historically, TBI management has been guided by clinical examination. This has been assisted progressively by clinical imaging, intracranial pressure (ICP) monitoring, and finally a software that can calculate optimal brain physiology. Multimodality monitoring affords clinicians an early indication of secondary insults to the recovering brain including raised ICP and decreased cerebral perfusion pressure. From variables such as ICP and arterial blood pressure, correlations can be drawn to determine parameters of cerebral autoregulation (pressure reactivity index) and "optimal cerebral perfusion pressure" at which the vasculature is most reactive. More recently, significant advances using both direct and near-infrared spectroscopy-derived brain oxygenation plus cerebral microdialysis to drive management have been described. Here in, we provide a perspective on the state-of-the-art techniques recently implemented in clinical practice for pediatric TBI.
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Geeraerts T, Velly L, Abdennour L, Asehnoune K, Audibert G, Bouzat P, Bruder N, Carrillon R, Cottenceau V, Cotton F, Courtil-Teyssedre S, Dahyot-Fizelier C, Dailler F, David JS, Engrand N, Fletcher D, Francony G, Gergelé L, Ichai C, Javouhey É, Leblanc PE, Lieutaud T, Meyer P, Mirek S, Orliaguet G, Proust F, Quintard H, Ract C, Srairi M, Tazarourte K, Vigué B, Payen JF. Management of severe traumatic brain injury (first 24hours). Anaesth Crit Care Pain Med 2017; 37:171-186. [PMID: 29288841 DOI: 10.1016/j.accpm.2017.12.001] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The latest French Guidelines for the management in the first 24hours of patients with severe traumatic brain injury (TBI) were published in 1998. Due to recent changes (intracerebral monitoring, cerebral perfusion pressure management, treatment of raised intracranial pressure), an update was required. Our objective has been to specify the significant developments since 1998. These guidelines were conducted by a group of experts for the French Society of Anesthesia and Intensive Care Medicine (Société francaise d'anesthésie et de réanimation [SFAR]) in partnership with the Association de neuro-anesthésie-réanimation de langue française (ANARLF), The French Society of Emergency Medicine (Société française de médecine d'urgence (SFMU), the Société française de neurochirurgie (SFN), the Groupe francophone de réanimation et d'urgences pédiatriques (GFRUP) and the Association des anesthésistes-réanimateurs pédiatriques d'expression française (ADARPEF). The method used to elaborate these guidelines was the Grade® method. After two Delphi rounds, 32 recommendations were formally developed by the experts focusing on the evaluation the initial severity of traumatic brain injury, the modalities of prehospital management, imaging strategies, indications for neurosurgical interventions, sedation and analgesia, indications and modalities of cerebral monitoring, medical management of raised intracranial pressure, management of multiple trauma with severe traumatic brain injury, detection and prevention of post-traumatic epilepsia, biological homeostasis (osmolarity, glycaemia, adrenal axis) and paediatric specificities.
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Affiliation(s)
- Thomas Geeraerts
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France.
| | - Lionel Velly
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Lamine Abdennour
- Département d'anesthésie-réanimation, groupe hospitalier Pitié-Salpêtrière, AP-HP, 75013 Paris, France
| | - Karim Asehnoune
- Service d'anesthésie et de réanimation chirurgicale, Hôtel-Dieu, CHU de Nantes, 44093 Nantes cedex 1, France
| | - Gérard Audibert
- Département d'anesthésie-réanimation, hôpital Central, CHU de Nancy, 54000 Nancy, France
| | - Pierre Bouzat
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Nicolas Bruder
- Service d'anesthésie-réanimation, Aix-Marseille université, CHU Timone, Assistance publique-Hôpitaux de Marseille, 13005 Marseille, France
| | - Romain Carrillon
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Vincent Cottenceau
- Service de réanimation chirurgicale et traumatologique, SAR 1, hôpital Pellegrin, CHU de Bordeaux, Bordeaux, France
| | - François Cotton
- Service d'imagerie, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite cedex, France
| | - Sonia Courtil-Teyssedre
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | | | - Frédéric Dailler
- Service d'anesthésie-réanimation, hôpital neurologique Pierre-Wertheimer, groupement hospitalier Est, hospices civils de Lyon, 69677 Bron, France
| | - Jean-Stéphane David
- Service d'anesthésie réanimation, centre hospitalier Lyon Sud, hospices civils de Lyon, 69495 Pierre-Bénite, France
| | - Nicolas Engrand
- Service d'anesthésie-réanimation, Fondation ophtalmologique Adolphe de Rothschild, 75940 Paris cedex 19, France
| | - Dominique Fletcher
- Service d'anesthésie réanimation chirurgicale, hôpital Raymond-Poincaré, université de Versailles Saint-Quentin, AP-HP, Garches, France
| | - Gilles Francony
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
| | - Laurent Gergelé
- Département d'anesthésie-réanimation, CHU de Saint-Étienne, 42055 Saint-Étienne, France
| | - Carole Ichai
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Étienne Javouhey
- Service de réanimation pédiatrique, hôpital Femme-Mère-Enfant, hospices civils de Lyon, 69677 Bron, France
| | - Pierre-Etienne Leblanc
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Thomas Lieutaud
- UMRESTTE, UMR-T9405, IFSTTAR, université Claude-Bernard de Lyon, Lyon, France; Service d'anesthésie-réanimation, hôpital universitaire Necker-Enfants-Malades, université Paris Descartes, AP-HP, Paris, France
| | - Philippe Meyer
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - Sébastien Mirek
- Service d'anesthésie-réanimation, CHU de Dijon, Dijon, France
| | - Gilles Orliaguet
- EA 08 Paris-Descartes, service de pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, 75743 Paris cedex 15, France
| | - François Proust
- Service de neurochirurgie, hôpital Hautepierre, CHU de Strasbourg, 67098 Strasbourg, France
| | - Hervé Quintard
- Service de réanimation médicochirurgicale, UMR 7275, CNRS, Sophia Antipolis, hôpital Pasteur, CHU de Nice, 06000 Nice, France
| | - Catherine Ract
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Mohamed Srairi
- Pôle anesthésie-réanimation, Inserm, UMR 1214, Toulouse neuroimaging center, ToNIC, université Toulouse 3-Paul Sabatier, CHU de Toulouse, 31059 Toulouse, France
| | - Karim Tazarourte
- SAMU/SMUR, service des urgences, hospices civils de Lyon, hôpital Édouard-Herriot, 69437 Lyon cedex 03, France
| | - Bernard Vigué
- Département d'anesthésie-réanimation, hôpital de Bicêtre, hôpitaux universitaires Paris-Sud, AP-HP, Le Kremlin-Bicêtre, France; Équipe TIGER, CNRS 1072-Inserm 5288, service d'anesthésie, centre hospitalier de Bourg en Bresse, centre de recherche en neurosciences, Lyon, France
| | - Jean-François Payen
- Pôle anesthésie-réanimation, CHU Grenoble-Alpes, 38043 Grenoble cedex 9, France
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Maas AIR, Menon DK, Adelson PD, Andelic N, Bell MJ, Belli A, Bragge P, Brazinova A, Büki A, Chesnut RM, Citerio G, Coburn M, Cooper DJ, Crowder AT, Czeiter E, Czosnyka M, Diaz-Arrastia R, Dreier JP, Duhaime AC, Ercole A, van Essen TA, Feigin VL, Gao G, Giacino J, Gonzalez-Lara LE, Gruen RL, Gupta D, Hartings JA, Hill S, Jiang JY, Ketharanathan N, Kompanje EJO, Lanyon L, Laureys S, Lecky F, Levin H, Lingsma HF, Maegele M, Majdan M, Manley G, Marsteller J, Mascia L, McFadyen C, Mondello S, Newcombe V, Palotie A, Parizel PM, Peul W, Piercy J, Polinder S, Puybasset L, Rasmussen TE, Rossaint R, Smielewski P, Söderberg J, Stanworth SJ, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Synnot A, Te Ao B, Tenovuo O, Theadom A, Tibboel D, Videtta W, Wang KKW, Williams WH, Wilson L, Yaffe K, Adams H, Agnoletti V, Allanson J, Amrein K, Andaluz N, Anke A, Antoni A, van As AB, Audibert G, Azaševac A, Azouvi P, Azzolini ML, Baciu C, Badenes R, Barlow KM, Bartels R, Bauerfeind U, Beauchamp M, Beer D, Beer R, Belda FJ, Bellander BM, Bellier R, Benali H, Benard T, Beqiri V, Beretta L, Bernard F, Bertolini G, Bilotta F, Blaabjerg M, den Boogert H, Boutis K, Bouzat P, Brooks B, Brorsson C, Bullinger M, Burns E, Calappi E, Cameron P, Carise E, Castaño-León AM, Causin F, Chevallard G, Chieregato A, Christie B, Cnossen M, Coles J, Collett J, Della Corte F, Craig W, Csato G, Csomos A, Curry N, Dahyot-Fizelier C, Dawes H, DeMatteo C, Depreitere B, Dewey D, van Dijck J, Đilvesi Đ, Dippel D, Dizdarevic K, Donoghue E, Duek O, Dulière GL, Dzeko A, Eapen G, Emery CA, English S, Esser P, Ezer E, Fabricius M, Feng J, Fergusson D, Figaji A, Fleming J, Foks K, Francony G, Freedman S, Freo U, Frisvold SK, Gagnon I, Galanaud D, Gantner D, Giraud B, Glocker B, Golubovic J, Gómez López PA, Gordon WA, Gradisek P, Gravel J, Griesdale D, Grossi F, Haagsma JA, Håberg AK, Haitsma I, Van Hecke W, Helbok R, Helseth E, van Heugten C, Hoedemaekers C, Höfer S, Horton L, Hui J, Huijben JA, Hutchinson PJ, Jacobs B, van der Jagt M, Jankowski S, Janssens K, Jelaca B, Jones KM, Kamnitsas K, Kaps R, Karan M, Katila A, Kaukonen KM, De Keyser V, Kivisaari R, Kolias AG, Kolumbán B, Kolundžija K, Kondziella D, Koskinen LO, Kovács N, Kramer A, Kutsogiannis D, Kyprianou T, Lagares A, Lamontagne F, Latini R, Lauzier F, Lazar I, Ledig C, Lefering R, Legrand V, Levi L, Lightfoot R, Lozano A, MacDonald S, Major S, Manara A, Manhes P, Maréchal H, Martino C, Masala A, Masson S, Mattern J, McFadyen B, McMahon C, Meade M, Melegh B, Menovsky T, Moore L, Morgado Correia M, Morganti-Kossmann MC, Muehlan H, Mukherjee P, Murray L, van der Naalt J, Negru A, Nelson D, Nieboer D, Noirhomme Q, Nyirádi J, Oddo M, Okonkwo DO, Oldenbeuving AW, Ortolano F, Osmond M, Payen JF, Perlbarg V, Persona P, Pichon N, Piippo-Karjalainen A, Pili-Floury S, Pirinen M, Ple H, Poca MA, Posti J, Van Praag D, Ptito A, Radoi A, Ragauskas A, Raj R, Real RGL, Reed N, Rhodes J, Robertson C, Rocka S, Røe C, Røise O, Roks G, Rosand J, Rosenfeld JV, Rosenlund C, Rosenthal G, Rossi S, Rueckert D, de Ruiter GCW, Sacchi M, Sahakian BJ, Sahuquillo J, Sakowitz O, Salvato G, Sánchez-Porras R, Sándor J, Sangha G, Schäfer N, Schmidt S, Schneider KJ, Schnyer D, Schöhl H, Schoonman GG, Schou RF, Sir Ö, Skandsen T, Smeets D, Sorinola A, Stamatakis E, Stevanovic A, Stevens RD, Sundström N, Taccone FS, Takala R, Tanskanen P, Taylor MS, Telgmann R, Temkin N, Teodorani G, Thomas M, Tolias CM, Trapani T, Turgeon A, Vajkoczy P, Valadka AB, Valeinis E, Vallance S, Vámos Z, Vargiolu A, Vega E, Verheyden J, Vik A, Vilcinis R, Vleggeert-Lankamp C, Vogt L, Volovici V, Voormolen DC, Vulekovic P, Vande Vyvere T, Van Waesberghe J, Wessels L, Wildschut E, Williams G, Winkler MKL, Wolf S, Wood G, Xirouchaki N, Younsi A, Zaaroor M, Zelinkova V, Zemek R, Zumbo F. Traumatic brain injury: integrated approaches to improve prevention, clinical care, and research. Lancet Neurol 2017; 16:987-1048. [DOI: 10.1016/s1474-4422(17)30371-x] [Citation(s) in RCA: 822] [Impact Index Per Article: 117.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 07/06/2017] [Accepted: 09/27/2017] [Indexed: 12/11/2022]
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Stenroos A, Handolin L. Head Injuries in Urban Environment Skiing and Snowboarding: A Retrospective Study on Injury Severity and Injury Mechanisms. Scand J Surg 2017; 107:166-171. [DOI: 10.1177/1457496917738866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Aim: During the last decade urban skiing and snowboarding has gained a lot of popularity. In urban skiing/snowboarding riders try to balance on handrails and jump off buildings. Previous studies in skiing and snowboarding accidents have mostly been conducted at hospitals located close to alpine terrain with big ski resort areas. The aim of this study is to evaluate the types and severity of traumatic brain injuries occurring in small, suburban hills and in urban environment, and to characterize injury patterns to find out the specific mechanisms of injuries behind. Materials and Methods: This study included all patients admitted to the Helsinki University Hospital Trauma Unit from 2006 to 2015 with a head injury (ICD 10 S06-S07) from skiing or snowboarding accidents in Helsinki capital area. Head injuries that did not require a CT-scan, and injuries older than 24 hours were excluded from this study. Results: There were a total of 72 patients that met the inclusion criteria Mean length of stay in hospital was 2.95 days. According to the AIS classification, 30% had moderate, 14% had severe, and 10% had critical head injuries. Patients who got injured in terrain parks or on streets where more likely to be admitted to ICU than those injured on slopes. Based on GOS score at discharge, 78% were classified as having a good recovery from the injury, 13% had a moderate disability, 5% had a severe disability and 3% of the injuries were fatal. There were no statistically significant differences in decreased GOS between the accident sites. Conclusion: Head injuries occurring in small suburban hills and in urban environments can be serious and potentially fatal. The profile and severity of skiing injuries in urban environments and small, suburban hills is comparable to those on alpine terrain.
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Affiliation(s)
- A. Stenroos
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
| | - L. Handolin
- Department of Orthopedics and Traumatology, Helsinki University Hospital, Helsinki, Finland
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Lecky FE, Russell W, McClelland G, Pennington E, Fuller G, Goodacre S, Han K, Curran A, Holliman D, Chapman N, Freeman J, Byers S, Mason S, Potter H, Coats T, Mackway-Jones K, Peters M, Shewan J. Bypassing nearest hospital for more distant neuroscience care in head-injured adults with suspected traumatic brain injury: findings of the head injury transportation straight to neurosurgery (HITS-NS) pilot cluster randomised trial. BMJ Open 2017; 7:e016355. [PMID: 28982816 PMCID: PMC5640033 DOI: 10.1136/bmjopen-2017-016355] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Reconfiguration of trauma services, with direct transport of patients with traumatic brain injury (TBI) to specialist neuroscience centres (SNCs)-bypassing non-specialist acute hospitals (NSAHs), could improve outcomes. However, delays in stabilisation of airway, breathing and circulation (ABC) may worsen outcomes when compared with selective secondary transfer from nearest NSAH to SNC. We conducted a pilot cluster randomised controlled trial to determine the feasibility and plausibility of bypassing suspected patients with TBI -directly into SNCs-producing a measurable effect. SETTING Two English Ambulance Services. PARTICIPANTS 74 clusters (ambulance stations) were randomised within pairs after matching for important characteristics. Clusters enrolled head-injured adults-injured nearest to an NSAH-with internationally accepted TBI risk factors and stable ABC. We excluded participants attended by Helicopter Emergency Medical Services or who were injured more than 1 hour by road from nearest SNC. INTERVENTIONS Intervention cluster participants were transported directly to an SNC bypassing nearest NSAH; control cluster participants were transported to nearest NSAH with selective secondary transfer to SNC. OUTCOMES Trial recruitment rate (target n=700 per annum) and percentage with TBI on CT scan (target 80%) were the primary feasibility outcomes. 30-day mortality, 6-month Extended Glasgow Outcome Scale and quality of life were secondary outcomes. RESULTS 56 ambulance station clusters recruited 293 patients in 12 months. The trial arms were similar in terms of age, conscious level and injury severity. Less than 25% of recruited patients had TBI on CT (n=70) with 7% (n=20) requiring neurosurgery. Complete case analysis showed similar 30-day mortality in the two trial arms (control=8.8 (2.7-14.0)% vs intervention=9.4(2.3-14.0)%). CONCLUSION Bypassing patients with suspected TBI to SNCs gives an overtriage (false positive) ratio of 13:1 for neurosurgical intervention and 4:1 for TBI. A measurable effect from a full trial of early neuroscience care following bypass is therefore unlikely. TRIAL REGISTRATION NUMBER ISRCTN68087745.
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Affiliation(s)
- Fiona Elizabeth Lecky
- Centre for Urgent and Emergency Care Research (CURE) Group, Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Wanda Russell
- Trauma Audit and Research Network, Centre for Occupational and Environmental Health, Institute of Population, University of Manchester, Manchester, UK
| | - Graham McClelland
- Research and Development Department, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Elspeth Pennington
- Research and Development Department, North West Ambulance Service, Carlisle, UK
| | - Gordon Fuller
- Centre for Urgent and Emergency Care Research (CURE) Group, Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- Centre for Urgent and Emergency Care Research (CURE) Group, Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Kyee Han
- Research and Development Department, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Andrew Curran
- Research and Development Department, North West Ambulance Service, Carlisle, UK
| | - Damian Holliman
- Department of Neurosurgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nathan Chapman
- Centre for Urgent and Emergency Care Research (CURE) Group, Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jennifer Freeman
- Centre for Urgent and Emergency Care Research (CURE) Group, Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sonia Byers
- Research and Development Department, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Suzanne Mason
- Centre for Urgent and Emergency Care Research (CURE) Group, Health Services Research, School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Hugh Potter
- Potter Rees Serious Injury Solicitors LLP, Manchester, UK
| | - Timothy Coats
- Department of Cardiovascular Sciences, University of Leicester/University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Kevin Mackway-Jones
- Research and Development Department, North West Ambulance Service, Carlisle, UK
| | - Mary Peters
- Research and Development Department, North West Ambulance Service, Carlisle, UK
| | - Jane Shewan
- Research and Development Department, Yorkshire Ambulance Services NHS Trust, Wakefield, UK
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Role of astrocyte connexin hemichannels in cortical spreading depression. BIOCHIMICA ET BIOPHYSICA ACTA-BIOMEMBRANES 2017; 1860:216-223. [PMID: 28864364 DOI: 10.1016/j.bbamem.2017.08.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 08/08/2017] [Accepted: 08/23/2017] [Indexed: 11/21/2022]
Abstract
Cortical spreading depression (CSD) is an intriguing phenomenon consisting of massive slow brain depolarizations that affects neurons and glial cells. It has been recognized since 1944, but its pathogenesis has only been uncovered during the last decade. Acute brain injuries can be further complicated by CSD in >50% of severe cases. This phenomenon is repetitive and produces a metabolic overload that increments secondary damage. Propagation of CSD is known to be linked to excitotoxicity, but the mechanisms associated with its initiation remain less understood. It has been shown that CSD can be initiated by increases in extracellular [K+] ([K+]e), and animal models use high [K+]e to promote CSD. Connexin hemichannel activity increases due to high [K+]e and low extracellular [Ca2+], conditions that occur after brain injury. Moreover, glial cell gap junction channels are fundamental in controlling extracellular medium composition, particularly in maintaining normal extracellular glutamate and K+ concentrations through "spatial buffering". However, the role of astrocytic gap junctions under tissue stress can change to damage spread in the acute damage zone whereas the reduced communication in adjacent zone would reduce cell dead propagation. Here, we review the main findings associated with CSD, and discuss the possible involvement of astrocytic connexin-based channels in secondary damage propagation. This article is part of a Special Issue entitled: Gap Junction Proteins edited by Jean Claude Herve.
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