Utilidad de la TAC secuencial y la monitorización de la presión intracraneal para detectar nuevo efecto masa intracraneal en pacientes con traumatismo craneal grave y lesión inicial Tipo I-II

Intracranial Hypertension with Patent Basal Cisterns: Controlled Lumbar Drainage as a Therapeutic Option. Selected Case Series

BACKGROUND

There are pathological conditions in which intracranial hypertension and patent basal cisterns in computed tomography coexist. These situations are not well recognized, which could lead to diagnostic errors and improper management.

METHODS

We present a retrospective case series of patients with traumatic brain injury, subarachnoid hemorrhage, and cryptococcal meningitis who were treated at our intensive care unit. Criteria for deciding placement of an external lumbar drain were (1) intracranial hypertension refractory to osmotherapy, hyperventilation, neuromuscular blockade, intravenous anesthesia, and, in some cases, decompressive craniectomy and (2) a computed tomography scan that showed open basal cisterns and no mass lesion.

RESULTS

Eleven patients were studied. Six of the eleven patients treated with controlled lumbar drainage are discussed as illustrative cases. All patients developed intracranial hypertension refractory to maximum medical treatment, including decompressive craniectomy in Four of the eleven cases. Controlled external lumbar drainage led to immediate and sustained control of elevated intracranial pressure in all patients, with good neurological outcomes. No brain herniation, intracranial bleeding, or meningitis was detected during this procedure.

CONCLUSIONS

Our study provides preliminary evidence that in selected patients who develop refractory intracranial hypertension with patent basal cisterns and no focal mass effect on computed tomography, controlled lumbar drainage appears to be a therapeutic option. In our study there were no deaths or complications. Prospective and larger studies are needed to confirm our results.

Intracranial compliance and volumetry in patients with traumatic brain injury

BACKGROUND

Cerebral edema (CE) and intracranial hypertension (IHT) are complications of numerous neurological pathologies. However, the study of CE and noninvasive methods to predict IHT remains rudimentary. This study aims to identify in traumatic brain injury (TBI) patients the relationship between the volume of the lateral ventricles and the parameters of the noninvasive intracranial pressure waveform (nICPW).

METHODS

This is an analytical, descriptive, and cross-sectional study with nonsurgical TBI patients. The monitoring of nICPW was performed with a mechanical strain gauge, and the volumetry of the lateral ventricles was calculated using the free 3D Slicer software, both during the acute phase of the injury. The linear model of fixed and random mixed effects with Gamma was used to calculate the influence of nICPW parameters (P2/P1 and time-to-peak [TTP]) values on volumetry.

RESULTS

Considering only the fixed effects of the sample, there was P = 0.727 (95% CI [-0.653; 0.364]) for the relationship between P2/P1 and volumetry and 0.727 (95% CI [-1.657; 1.305]) for TTP and volumetry. Considering the fixed and random effects, there was P = 8.5e-10 (95% CI [-0.759; 0.355]) for the relationship between P2/P1 and volumetry and 8.5e-10 (95% CI [-2.001; 0.274]) for TTP and volumetry.

CONCLUSION

The present study with TBI patients found association between nICPW parameters and the volume of the lateral ventricles in the 1st days after injury.

Mild-to-Moderate Traumatic Brain Injury: A Review with Focus on the Visual System

Traumatic Brain Injury (TBI) is a major global public health problem. Neurological damage from TBI may be mild, moderate, or severe and occurs both immediately at the time of impact (primary injury) and continues to evolve afterwards (secondary injury). In mild (m)TBI, common symptoms are headaches, dizziness and fatigue. Visual impairment is especially prevalent. Insomnia, attentional deficits and memory problems often occur. Neuroimaging methods for the management of TBI include computed tomography and magnetic resonance imaging. The location and the extent of injuries determine the motor and/or sensory deficits that result. Parietal lobe damage can lead to deficits in sensorimotor function, memory, and attention span. The processing of visual information may be disrupted, with consequences such as poor hand-eye coordination and balance. TBI may cause lesions in the occipital or parietal lobe that leave the TBI patient with incomplete homonymous hemianopia. Overall, TBI can interfere with everyday life by compromising the ability to work, sleep, drive, read, communicate and perform numerous activities previously taken for granted. Treatment and rehabilitation options available to TBI sufferers are inadequate and there is a pressing need for new ways to help these patients to optimize their functioning and maintain productivity and participation in life activities, family and community.

Intravenous Tranexamic Acid for Subdural and Epidural Intracranial Hemorrhage: Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

Recovery of patients with traumatic brain injury largely depends on the reduction in secondary brain damage. The present study aims at investigating the effect of Tranexamic Acid (TXA) administration within the first hours of brain trauma in the emergency department (ED).

METHODS

This randomized, double-blind, placebo-controlled clinical trial was carried out in patients with subdural and epidural hemorrhage. Patients with any type of bleeding were assigned into two groups of TXA and 0.9% normal saline as placebo. The rate of intracranial hemorrhage after surgery was assessed by CT-scan and amount of hemoglobin (Hb) was measured immediately before surgery and after 6 hours of surgery.

RESULTS

A total of 80 participants were randomly assigned into four groups of 20 people. There was a significant difference in the mean of intraoperative bleeding during surgery in patients receiving TXA and placebo in both SDH (Subdural hematoma) and EDH (Epidural Hemorrhage) groups (P= 0.012). The Hb drop amount had no significant difference with placebo (P< 0.0001). No complications were observed in any of the intervention and control groups during the study as well.

CONCLUSION

The use of TXA may reduce bleeding, however, based on the results of this study, such effect was not statistically significant in controlling the epidural and subdural hemorrhage, but clinical trials with a higher sample size are suggested for further investigation in this regard.

Therapeutic Effect of Enteral Nutrition Supplemented with Probiotics in the Treatment of Severe Craniocerebral Injury: A Systematic Review and Meta-Analysis

BACKGROUND

Whether early enteral nutrition with probiotics can reduce the mortality and infection rate of patients with severe craniocerebral injury (SCI), improve their gastrointestinal function, and shorten the length of stay in the intensive care unit (ICU) has not been determined.

METHODS

PubMed, China National Knowledge Infrastructure, and Embase were electronically searched for the purpose of identifying randomized controlled trials investigated the potential of early enteral nutrition supplemented with probiotics on patients with SCI from the establishment of databases to August 26, 2019. STATA software version 12.0 was used to perform meta-analysis.

RESULTS

A total of 39 trials enrolling 3387 patients were included. Early enteral nutrition supplemented with probiotics was associated with decreased risk of infection (pooled risk ratio [RR], 0.486; 95% confidence interval [CI], 0.394-0.599), decreased risk of 7-, 14-, and 28-day mortality (pooled RRs, 0.415, 0.497, and 0.385; 95% CIs, 0.196-0.878, 0.297-0.833, and 0.197-0.751, respectively), and decreased risk of gastrointestinal complications (pooled RR, 0.363; 95% CI, 0.274-0.481). It also shortened the time course recovery of enteral function and shortened the length of stay in hospital and length of ICU stay (standardized mean differences, -3.327 and -1.461; 95% CIs, -6.213 to -0.440 and -2.111 to -0.811, respectively).

CONCLUSIONS

Enteral nutrition supplemented with probiotics effectively decreases the risk of mortality, gastrointestinal complications, and infection, and shortens the stays in ICU; therefore, it should be extensively adopted to manage these given patients.

Early enteral nutrition supplemented with probiotics improved the clinical outcomes in severe head injury: Some promising findings from Chinese patients

BACKGROUND

The role of early enteral nutrition (ENN) supplemented with probiotics (<48 hours) in improving clinical outcomes of patients with severe head injury (SHI) remains controversial. We performed this meta-analysis to investigate the efficacy of EEN supplemented with probiotics on clinical outcomes in these patients.

METHODS

Systematic searches were performed in PubMed, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Wanfang database, and Chinese Biomedical Literature to identify potential studies. Two investigators checked citations, extracted data, appraised risk of bias, and then STATA 12.0 was used to perform statistical analysis.

RESULTS

A total of 18 trials were eventually included in the present study. Meta-analysis indicated that EEN supplemented with probiotics was associated with decreased risk of infection (risk ratio [RR], 0.53; 95% confidence interval [CI], 0.44-0.65), decreased risk of mortality (RR, 0.56; 95% CI, 0.38-0.82), decreased risk of gastrointestinal complications (RR, 0.19; 95% CI, 0.13-0.25), and shortened stays in intensive care unit (ICU) (mean difference [MD], -4.55; 96% CI, -5.91 to -3.19).

CONCLUSION

EEN supplemented with probiotics may be a promising alternative for patients with SHI because it effectively decreased the risk of infection, mortality, and gastrointestinal complications, as well as shortened the stays in ICU.

Effect of Tranexamic Acid on Prevention of Hemorrhagic Mass Growth in Patients with Traumatic Brain Injury

BACKGROUND

Intracranial hemorrhage is a common complication of traumatic brain injury (TBI). The purpose of this study is evaluation of the effect of tranexamic acid (TXA) on hemorrhagic mass growth in TBI patients.

PATIENTS AND METHODS

In this randomized, double-blind clinical trial, 149 patients with TBI and any kind of blood on their computed tomography scan enrolled in the study and were randomly allocated to receive TXA or placebo. After 24 hours, computed tomography scan was repeated for assessing the changes in hemorrhage, new bleeding, and mass effects of blood on brain tissue. The primary outcome was growth of the hemorrhagic lesion. Data were analyzed by SPSS software using Fisher exact, chi-square, and Mann-Whitney U tests, as well as linear and logistic regression models.

FINDINGS

The incidence of hemorrhagic lesion growth was 20.5% in the TXA group and 22.7% in the placebo group. The difference was not significant (P = 0.87, RR = 0.89). The mean (standard deviation) of hemorrhagic lesion growth was 9.4 (15.3) in the TXA group and 10.2 (10.1) in the placebo group without significant difference (P = 0.27). The frequency of deaths (2.7% vs. 4%), adverse outcome at discharge (10.8% vs. 17.3%), and 3 months later (6.8% vs. 14.7%) in the TXA group were lower than the placebo, but the difference was not statistically significant. No side effect was observed with the administration of TXA.

CONCLUSION

Administration of a short dose of TXA does not lead to significant prevention of growth of posttraumatic hemorrhagic lesion or improvement of clinical outcomes.

Management of Refractory Intracranial Pressure

Patients with refractory intracranial pressure represent a challenge to the multidisciplinary critical care team. Myriad diagnoses: traumatic brain injury, subarachnoid hemorrhage, intracranial hemorrhage, and ischemic stroke, are among the causes commonly seen in patients with elevated intracranial pressure. Clinicians tasked with caring for these patients must be aware of available interventions and management strategies to improve outcomes. Nurses as the bedside clinician most frequently assessing these patients are ideally situated to detect changes and act efficiently to lower refractory intracranial pressure.

Contrecoup Traumatic Intracerebral Hemorrhage: A Geometric Study of the Impact Site and Association with Hemorrhagic Progression

Traumatic intracerebral hemorrhage (TICH) represents 13-48% of the lesions after a traumatic brain injury (TBI). The frequency of TICH-hemorrhagic progression (TICH-HP) is estimated to be approximately 38-63%. The relationship between the impact site and TICH location has been described in many autopsy-based series. This association, however, has not been consistently demonstrated since the introduction of computed tomography (CT) for studying TBI. This study aimed to determine the association between the impact site and TICH location in patients with moderate and severe TBI. We also analyzed the associations between the TICH location, the impact site, the production mechanism (coup or contrecoup), and hemorrhagic progression. We retrospectively analyzed the records of 408 patients after a moderate or severe TBI between January 2010 and November 2014. We identified 177 patients with a total of 369 TICHs. We found a statistically significant association between frontal TICHs and impact sites located on the anterior area of the head (OR 5.8, p < 0.001). The temporal TICH location was significantly associated with impact sites located on the posterior head area (OR 4.9, p < 0.001). Anterior and lateral TICHs were associated with impact sites located at less than 90 degrees (coup) (OR 1.64, p = 0.03) and more than 90 degrees (contrecoup), respectively. Factors independently associated with TICH-HP obtained through logistic regression included an initial volume of <1 cc, cisternal compression, falls, acute subdural hematoma, multiple TICHs, and contrecoup TICHs. We demonstrated a significant association between the TICH location and impact site. The contrecoup represents a risk factor independently associated with hemorrhagic progression.

Value of repeat head computed tomography after traumatic brain injury: systematic review and meta-analysis

Diagnosis and management of traumatic brain injury (TBI) is crucial to improve patient outcomes. While initial head computed tomography (CT) scan is the optimum tool for quick and accurate detection of intracranial hemorrhage, the guidelines on use of repeat CT differ among institutions. Three systematic reviews have been conducted on a similar topic; none have performed a comprehensive meta-analysis of all studies. Search of Medline, the Cochrane Library database, and Clinicaltrials.gov , and a hand search of conference abstracts and references for all completed studies reporting data on change in management following repeat CT was conducted. Two authors reviewed all studies and extracted data using a standardized form. A proportional meta-analysis was conducted using the random-effects model for outcomes related to any change in management following repeat CT. Any change in management included intracranial intervention, change in intracranial pressure monitoring, and/or administration of drug therapy. Search results yielded 6982 references. In all, 41 studies enrolling 10,501 patients were included. Change in management following repeat CT was reported in 13 prospective and 28 retrospective studies and yielded a pooled proportion of 11.4% (95% confidence interval [CI] 5.9-18.4) and 9.6% (95% CI 6.5-13.2), respectively. In a subgroup analysis of mild TBI patients (Glasgow Coma Scale score 13 to 15), five prospective and nine retrospective studies reported on change in management following repeat CT with the pooled proportion across prospective studies at 2.3% (95% CI 0.3-6.3) and across retrospective studies at 3.9% (95% CI 2.3-5.7), respectively. The evidence suggests that repeat CT in patients with TBI results in a change in management for only a minority of patients. Better designed studies are needed to address the issue of the value of repeat CT in the management of TBI.

Traumatic cervical artery dissection in head injury: the value of follow-up brain imaging

INTRODUCTION

Traumatic cervical artery dissection (TCAD) is a relative infrequent complication of traumatic brain injury (TBI). Since TCAD is associated with morbidity in a considerable percentage of patients, it is important to obtain clues for recognising TCAD in this category of patients.

METHODS

Retrospective case-cohort study in severe TBI patients.

RESULTS

Five patients with traumatic cervical artery dissection after severe TBI, leading to ischemic strokes, are described. Secondary deterioration to coma was present in four out of five patients during admission. The diagnosis of TCAD was delayed in most cases because the secondary deterioration was often attributed to multisystem problems related to trauma patients, i.e. shock or hypoxia or medication effects. Local clinical symptoms and signs suggestive of TCAD are difficult to detect in this patient group. In all patients, the CT-scan on admission demonstrated no abnormalities. A follow-up scan at day 2 revealed that in all patients abnormalities in the vascular territories had evolved.

CONCLUSION

With this case-cohort study we underline the importance of considering TCAD in severe TBI patients and emphasise the role for standard follow-up brain imaging. Also possible treatment consequences are discussed.

Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?

Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or "Will Rogers" phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.