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Baker CE, Yu X, Lovell B, Tan R, Patel S, Ghajari M. How Well Do Popular Bicycle Helmets Protect from Different Types of Head Injury? Ann Biomed Eng 2024:10.1007/s10439-024-03589-8. [PMID: 39294466 DOI: 10.1007/s10439-024-03589-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Accepted: 07/25/2024] [Indexed: 09/20/2024]
Abstract
Bicycle helmets are designed to protect against skull fractures and associated focal brain injuries, driven by helmet standards. Another type of head injury seen in injured cyclists is diffuse brain injuries, but little is known about the protection provided by bicycle helmets against these injuries. Here, we examine the performance of modern bicycle helmets in preventing diffuse injuries and skull fractures under impact conditions that represent a range of real-world incidents. We also investigate the effects of helmet technology, price, and mass on protection against these pathologies. 30 most popular helmets among UK cyclists were purchased within 9.99-135.00 GBP price range. Helmets were tested under oblique impacts onto a 45° anvil at 6.5 m/s impact speed and four locations, front, rear, side, and front-side. A new headform, which better represents the average human head's mass, moments of inertia and coefficient of friction than any other available headforms, was used. We determined peak linear acceleration (PLA), peak rotational acceleration (PRA), peak rotational velocity (PRV), and BrIC. We also determined the risk of skull fractures based on PLA (linear risk), risk of diffuse brain injuries based on BrIC (rotational risk), and their mean (overall risk). Our results show large variation in head kinematics: PLA (80-213 g), PRV (8.5-29.9 rad/s), PRA (1.6-9.7 krad/s2), and BrIC (0.17-0.65). The overall risk varied considerably with a 2.25 ratio between the least and most protective helmet. This ratio was 1.76 for the linear and 4.21 for the rotational risk. Nine best performing helmets were equipped with the rotation management technology MIPS, but not all helmets equipped with MIPS were among the best performing helmets. Our comparison of three tested helmets which have MIPS and no-MIPS versions showed that MIPS reduced rotational kinematics, but not linear kinematics. We found no significant effect of helmet price on exposure-adjusted injury risks. We found that larger helmet mass was associated with higher linear risk. This study highlights the need for a holistic approach, including both rotational and linear head injury metrics and risks, in helmet design and testing. It also highlights the need for providing information about helmet safety to consumers to help them make an informed choice.
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Affiliation(s)
- C E Baker
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, London, SW7 2AZ, UK.
| | - X Yu
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, London, SW7 2AZ, UK
- Department of Mechanical Engineering, University of Sheffield, Sheffield, S10 2TN, UK
| | - B Lovell
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, London, SW7 2AZ, UK
| | - R Tan
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, London, SW7 2AZ, UK
| | - S Patel
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, London, SW7 2AZ, UK
| | - M Ghajari
- HEAD Lab, Dyson School of Design Engineering, Imperial College London, London, SW7 2AZ, UK
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Murase M, Yasuda S, Sawano M. Prediction for the prognosis of diffuse axonal injury using automated pupillometry. Clin Neurol Neurosurg 2024; 240:108244. [PMID: 38520767 DOI: 10.1016/j.clineuro.2024.108244] [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: 12/09/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVE Previous studies have reported various predictive indicators of diffuse axonal injury (DAI), but no consensus has not been reached. Although the efficiency of automated pupillometry in patients with consciousness disorder has been widely reported, there are few reports of its use in patients with DAI. This study aimed to investigate the significance of pupillary findings in predicting the prognosis of DAI. PATIENTS AND METHODS We included patients admitted to our center with a diagnosis of DAI from June 1, 2021 to June 30, 2022. Pupillary findings in both eyes were quantitatively measured by automated pupillometry every 2 hours after admission. We statistically examined the correlations between automated pupillometry parameters, the patients' characteristics, and outcomes such as the Glasgow Outcome Scale Extended (GOSE) after 6 months from injury, the time to follow command, and so on. RESULTS Among 22 patients included in this study, five had oculomotor nerve palsy. Oculomotor nerve palsy was correlated with all outcomes, whereas Marshall computed tomography (CT) classification, Injury severity score (ISS) and DAI grade were correlated with few outcomes. Some of the automated pupillometry parameters were significantly correlated with GOSE at 6 months after injury, and many during the first 24 hours of measurement were correlated with the time to follow command. Most of these results were not affected by adjustment using sedation period, ISS or Marshall CT classification. A subgroup analysis of patients without oculomotor nerve palsy revealed that many of the automated pupillometry parameters during the first 24 hours of measurement were significantly correlated with most of the outcomes. The cutoff values that differentiated a good prognosis (GOSE 5-8) from a poor prognosis (GOSE 1-4) were constriction velocity (CV) 1.43 (AUC = 0.81(0.62-1), p = 0.037) and maximum constriction velocity (MCV) 2.345 (AUC = 0.78 (0.58-0.98), p = 0.04). The cutoff values that differentiated the time to follow command into within 7 days and over 8 days were percentage of constriction 8 (AUC = 0.89 (0.68-1), p = 0.011), CV 0.63 (AUC = 0.92 (0.78-1), p = 0.013), MCV 0.855 (AUC = 0.9 (0.74-1), p = 0.017) and average dilation velocity 0.175 (AUC = 0.95 (0.86-1), p = 0.018). CONCLUSIONS The present results indicate that pupillary findings in DAI are a strong predictive indicator of the prognosis, and that quantitative measurement of them using automated pupillometry could facilitate enhanced prediction for the prognosis of DAI.
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Affiliation(s)
- Makoto Murase
- Department of Emergency Medicine and Critical Care, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan.
| | - Shinichi Yasuda
- Department of Emergency Medicine and Critical Care, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
| | - Makoto Sawano
- Department of Emergency Medicine and Critical Care, Saitama Medical University, 1981 Kamoda, Kawagoe, Saitama 350-8550, Japan
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Vieira RDCA, Pipek LZ, de Oliveira DV, Paiva WS, de Sousa RMC. The Relationship between Injury Characteristics and Post-Traumatic Recovery after Diffuse Axonal Injury. Biomedicines 2024; 12:311. [PMID: 38397913 PMCID: PMC10886783 DOI: 10.3390/biomedicines12020311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Revised: 12/28/2023] [Accepted: 01/03/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND The diagnosis and prognosis of diffuse axonal injury (DAI) remain challenging. This research aimed to analyze the impact on activities of daily living (ADL), functional outcomes, quality of life (QoL), and the association between lesion severity and DAI location identified through imaging exams. METHODS This prospective cohort study included 95 patients diagnosed with DAI. Data were collected at admission, three, six, and twelve months post-injury. The associations between variables were evaluated using a mixed-effects model. RESULTS Functional recovery and QoL improved between three and twelve months after DAI. An interaction was observed between independence in performing ADL and subarachnoid hemorrhage (p = 0.043) and intraventricular hemorrhage (p = 0.012). Additionally, an interaction over time was observed between the Glasgow Outcome Scale (GOS) and DAI severity (p < 0.001), brain lesions (p = 0.014), and the Disability Rating Scale (DRS) with injury in brain hemispheres (p = 0.026) and Adams classification (p = 0.013). Interaction effects over time were observed with the general health perceptions and energy/vitality domains with intraventricular hemorrhage, and the social functioning domain with the obliteration of basal cisterns and Gentry's classification. CONCLUSION The use of CT in the acute phase of DAI is important for predicting outcomes. The severity and location of DAI are associated with functional outcomes, ADL, and QoL.
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Affiliation(s)
- Rita de Cássia Almeida Vieira
- Department of Nursing, University of Sergipe, Lagarto 49400-000, Brazil;
- Nursing School, University of Sao Paulo, Sao Paulo 05508-010, Brazil;
| | - Leonardo Zumerkorn Pipek
- Department of Neurology, Clinical Hospital of the University of Sao Paulo, University of Sao Paulo Medical School, Sao Paulo 05403-000, Brazil
| | | | - Wellingson Silva Paiva
- Division of Neurosurgery, Clinical Hospital of the University of Sao Paulo, University of Sao Paulo Medical School, Sao Paulo 05403-000, Brazil;
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Yu F, Iacono D, Perl DP, Lai C, Gill J, Le TQ, Lee P, Sukumar G, Armstrong RC. Neuronal tau pathology worsens late-phase white matter degeneration after traumatic brain injury in transgenic mice. Acta Neuropathol 2023; 146:585-610. [PMID: 37578550 PMCID: PMC10499978 DOI: 10.1007/s00401-023-02622-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 08/08/2023] [Accepted: 08/08/2023] [Indexed: 08/15/2023]
Abstract
Traumatic brain injury (TBI) causes diffuse axonal injury which can produce chronic white matter pathology and subsequent post-traumatic neurodegeneration with poor patient outcomes. Tau modulates axon cytoskeletal functions and undergoes phosphorylation and mis-localization in neurodegenerative disorders. The effects of tau pathology on neurodegeneration after TBI are unclear. We used mice with neuronal expression of human mutant tau to examine effects of pathological tau on white matter pathology after TBI. Adult male and female hTau.P301S (Tg2541) transgenic and wild-type (Wt) mice received either moderate single TBI (s-TBI) or repetitive mild TBI (r-mTBI; once daily × 5), or sham procedures. Acutely, s-TBI produced more extensive axon damage in the corpus callosum (CC) as compared to r-mTBI. After s-TBI, significant CC thinning was present at 6 weeks and 4 months post-injury in Wt and transgenic mice, with homozygous tau expression producing additional pathology of late demyelination. In contrast, r-mTBI did not produce significant CC thinning except at the chronic time point of 4 months in homozygous mice, which exhibited significant CC atrophy (- 29.7%) with increased microgliosis. Serum neurofilament light quantification detected traumatic axonal injury at 1 day post-TBI in Wt and homozygous mice. At 4 months, high tau and neurofilament in homozygous mice implicated tau in chronic axon pathology. These findings did not have sex differences detected. Conclusions: Neuronal tau pathology differentially exacerbated CC pathology based on injury severity and chronicity. Ongoing CC atrophy from s-TBI became accompanied by late demyelination. Pathological tau significantly worsened CC atrophy during the chronic phase after r-mTBI.
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Affiliation(s)
- Fengshan Yu
- Department of Anatomy, Physiology and Genetics, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Diego Iacono
- Neurology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Department of Defense-Uniformed Services University Brain Tissue Repository, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Daniel P Perl
- Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Department of Defense-Uniformed Services University Brain Tissue Repository, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Chen Lai
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | | | - Tuan Q Le
- Department of Anatomy, Physiology and Genetics, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
| | - Patricia Lee
- Pathology, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Department of Defense-Uniformed Services University Brain Tissue Repository, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Gauthaman Sukumar
- Department of Anatomy, Physiology and Genetics, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Regina C Armstrong
- Department of Anatomy, Physiology and Genetics, School of Medicine, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, USA.
- Center for Neuroscience and Regenerative Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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Laic RAG, Verheyden J, Bruyninckx D, Lebegge P, Sloten JV, Depreitere B. Profound prospective assessment of radiological and functional outcome 6 months after TBI in elderly. Acta Neurochir (Wien) 2023; 165:849-864. [PMID: 36922467 DOI: 10.1007/s00701-023-05546-1] [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: 01/17/2023] [Accepted: 03/02/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Recovery after traumatic brain injury (TBI) in older adults is usually affected by the presence of comorbidities, leading to more severe sequelae in this age group than in younger patients. However, there are only few reports that prospectively perform in-depth assessment of outcome following TBI in elderly. OBJECTIVE This study aims at documenting structural brain characteristics and functional outcome and quality of life in elderly patients 6 months after TBI and comparing these data with healthy volunteers undergoing the same assessments. METHODS Thirteen TBI patients ≥ 65 years old, admitted to the University Hospitals Leuven (Belgium), between 2019 and 2022 due to TBI, including all injury severities, and a group of 13 healthy volunteers with similar demographic characteristics were prospectively included in the study. At admission, demographic, injury, and CT scan data were collected in our database. Six months after the accident, a brain MRI scan and standardized assessments of frailty, sleep quality, cognitive function, motor function, and quality of life were conducted. RESULTS A total of 13 patients and 13 volunteers were included in the study, with a median age of 74 and 73 years, respectively. Nine out of the 13 patients presented with a mild TBI. The patient group had a significantly higher level of frailty than the control group, presenting a mean Reported Edmonton Frailty Scale score of 5.8 (SD 2.7) vs 0.7 (SD 1.1) (p < 0.01). No statistically significant differences were found between patient and control brain volumes, fluid attenuated inversion recovery white matter hyperintensity volumes, number of lesions and blackholes, and fractional anisotropy values. Patients demonstrated a significantly higher median reaction time in the One Touch Stockings of Cambridge (22.3 s vs 17.6, p = 0.03) and Reaction Time (0.5 s vs 0.4 s, p < 0.01) subtests in the Cambridge Neuropsychological Test Automated Battery. Furthermore, patients had a lower mean score on the first Box and Blocks test with the right hand (46.6 vs 61.7, p < 0.01) and a significantly higher mean score in the Timed-Up & Go test (13.1 s vs 6.2 s, p = 0.02) and Timed Up & Go with cognitive dual task (16.0 s vs 10.2 s, p < 0.01). Substantially lower QOLIBRI total score (60.4 vs 85.4, p < 0.01) and QOLIBRI-OS total score (53.8 vs 88.5, p < 0.01) were also observed in the patients' group. CONCLUSION In this prospective study, TBI patients ≥ 65 years old when compared with elder controls showed slightly worse cognitive performance and poorer motor function, higher fall risk, but a substantially reduced QoL at 6 months FU, as well as significantly higher frailty, even when the TBI is classified as mild. No statistically significant differences were found in structural brain characteristics on MRI. Future studies with larger sample sizes are needed to refine the impact of TBI versus frailty on function and QoL in elderly.
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Chen W, Yao C, Li S, Huang H, Zhu Z, Chen R, Su W, Huang X, Xu L, Sun K, Song J, Jiang R, Wang G. Cognitive impairment in diffuse axonal injury patients with favorable outcome. Front Neurosci 2023; 17:1077858. [PMID: 36761409 PMCID: PMC9905128 DOI: 10.3389/fnins.2023.1077858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 01/09/2023] [Indexed: 01/26/2023] Open
Abstract
Background and purpose Traumatic brain injury (TBI), especially the severe TBI are often followed by persistent cognitive sequalae, including decision-making difficulties, reduced neural processing speed and memory deficits. Diffuse axonal injury (DAI) is classified as one of the severe types of TBI. Part of DAI patients are marginalized from social life due to cognitive impairment, even if they are rated as favorable outcome. The purpose of this study was to elucidate the specific type and severity of cognitive impairment in DAI patients with favorable outcome. Methods The neurocognition of 46 DAI patients with favorable outcome was evaluated by the Chinese version of the Montreal Cognitive Assessment Basic (MoCA-BC), and the differences in the domains of cognitive impairment caused by different grades of DAI were analyzed after data conversion of scores of nine cognitive domains of MoCA-BC by Pearson correlation analysis. Results Among the 46 DAI patients with favorable outcome, eight had normal cognitive function (MoCA-BC ≥ 26), and 38 had cognitive impairment (MoCA-BC < 26). The MoCA-BC scores were positively correlated with pupillary light reflex (r = 0.361, p = 0.014), admission Glasgow Coma Scale (GCS) (r = 0.402, p = 0.006), and years of education (r = 0.581, p < 0.001). Return of consciousness (r = -0.753, p < 0.001), Marshall CT (r = -0.328, p = 0.026), age (r = -0.654, p < 0.001), and DAI grade (r = -0.403, p = 0.006) were found to be negatively correlated with the MoCA-BC scores. In patients with DAI grade 1, the actually deducted scores (Ads) of memory (r = 0.838, p < 0.001), abstraction (r = 0.843, p < 0.001), and calculation (r = 0.782, p < 0.001) were most related to the Ads of MoCA-BC. The Ads of nine cognitive domains and MoCA-BC were all proved to be correlated, among patients with DAI grade 2. However, In the DAI grade 3 patients, the highest correlation with the Ads of MoCA-BC were the Ads of memory (r = 0.904, p < 0.001), calculation (r = 0.799, p = 0.006), orientation (r = 0.801, p = 0.005), and executive function (r = 0.869, p = 0.001). Conclusion DAI patients with favorable outcome may still be plagued by cognitive impairment, and different grades of DAI cause different domains of cognitive impairment.
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Affiliation(s)
- Weiliang Chen
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Chunyu Yao
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Shengwen Li
- The Second Department of Orthopaedics, Haining People’s Hospital, Haining, Zhejiang, China
| | - Hongguang Huang
- Department of Neurosurgery, The First Affiliated Hospital of Zhejiang University Medical College, Hangzhou, Zhejiang, China
| | - Zujian Zhu
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Rui Chen
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Wen Su
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Xiao Huang
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Lisheng Xu
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Kaijie Sun
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Jiannan Song
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China,Rongcai Jiang,
| | - Guanjun Wang
- Department of Neurosurgery, Haining People’s Hospital, Jiaxing, Zhejiang, China,*Correspondence: Guanjun Wang,
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Return to work after mild traumatic brain injury: association with positive CT and MRI findings. Acta Neurochir (Wien) 2022; 164:1707-1717. [PMID: 35639189 PMCID: PMC9233630 DOI: 10.1007/s00701-022-05244-4] [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: 02/17/2022] [Accepted: 05/10/2022] [Indexed: 11/07/2022]
Abstract
Background Return to work (RTW) might be delayed in patients with complicated mild traumatic brain injury (MTBI), i.e., MTBI patients with associated traumatic intracranial lesions. However, the effect of different types of lesions on RTW has not studied before. We investigated whether traumatic intracranial lesions detected by CT and MRI are associated with return to work and post-concussion symptoms in patients with MTBI. Methods We prospectively followed up 113 adult patients with MTBI that underwent a brain MRI within 3–17 days after injury. Return to work was assessed with one-day accuracy up to one year after injury. Rivermead Post-Concussion Symptoms Questionnaire (RPQ) and Glasgow Outcome Scale Extended (GOS-E) were conducted one month after injury. A Kaplan–Meier log-rank analysis was performed to analyze the differences in RTW. Results Full RTW-% one year after injury was 98%. There were 38 patients with complicated MTBI, who had delayed median RTW compared to uncomplicated MTBI group (17 vs. 6 days), and more post-concussion symptoms (median RPQ 12.0 vs. 6.5). Further, RTW was more delayed in patients with multiple types of traumatic intracranial lesions visible in MRI (31 days, n = 19) and when lesions were detected in the primary CT (31 days, n = 24). There were no significant differences in GOS-E. Conclusions The imaging results that were most clearly associated with delayed RTW were positive primary CT and multiple types of lesions in MRI. RTW-% of patients with MTBI was excellent and a single intracranial lesion does not seem to be a predictive factor of disability to work.
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Young MJ, Sanders WR, Marujo R, Bodien YG, Edlow BL. Return to Work Within Four Months of Grade 3 Diffuse Axonal Injury. Neurohospitalist 2022; 12:280-284. [PMID: 35419140 PMCID: PMC8995586 DOI: 10.1177/19418744211051459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Neuroprognostication following diffuse axonal injury (DAI) has historically relied on neuroimaging techniques with lower spatial resolution and contrast than techniques currently available in clinical practice. Since the initial studies of DAI classification and prognosis in the 1980s and 1990s, advances in neuroimaging have improved detection of brainstem microbleeds, a hallmark feature of Grade 3 DAI that has traditionally been associated with poor neurologic outcome. Here, we report clinical and radiologic data from two patients with severe traumatic brain injury and grade 3 DAI who recovered functional independence and returned to work within 4 months of injury. Importantly, both patients were scanned using 3 Tesla MRI protocols that included susceptibility-weighted imaging (SWI), a technique that provides enhanced sensitivity for detecting brainstem microbleeds. These observations highlight the importance of developing approaches to DAI classification and prognosis that better align with contemporary neuroimaging capabilities.
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Affiliation(s)
- Michael J. Young
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Safra Center for Ethics, Harvard University, Cambridge, MA, USA
| | - William R. Sanders
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Rose Marujo
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Yelena G. Bodien
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Harvard Medical School, Charlestown, MA, USA
| | - Brian L. Edlow
- Center for Neurotechnology and Neurorecovery, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Charlestown, MA, USA
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Zuckerman DA, Giacino JT, Bodien YG. Traumatic Brain Injury: What Is a Favorable Outcome? J Neurotrauma 2021; 39:1010-1012. [PMID: 34861770 DOI: 10.1089/neu.2021.0356] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Traumatic brain injury (TBI) results in disparate outcomes ranging from persistent disorders of consciousness to symptom resolution. Despite the breadth and complexity of TBI recovery, most clinical trials dichotomize outcome by establishing an arbitrary cut-point, above and below which recovery is described as "favorable" and "unfavorable," respectively. For example, the widely used eight-level Glasgow Outcome Scale-Extended (GOSE) is typically collapsed into these two categories. Dichotomizing the GOSE into "favorable" and "unfavorable" outcome may limit detection of treatment effects in TBI clinical trials, contribute to imprecise prognostic counseling, and unduly influence decision-making with regard to withdrawal of life-sustaining therapy. We illustrate the lack of standardization in defining "unfavorable" and "favorable" TBI outcome on the GOSE by identifying the broad range of cut-points, from a score of 3 (part-time supervision in the home required) to 7 (presence of some residual of symptoms), that have been used to dichotomize the GOSE. We also highlight the ethical concerns related to characterizing TBI outcomes solely from the perspective of investigators and clinicians, rather than patients and caregivers. Finally, we suggest that a pragmatic, immediate solution to GOSE dichotomization is to report the likelihood of achieving each of the eight GOSE outcome levels and propose a study design for a new patient- and caregiver-centered TBI outcome metric.
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Affiliation(s)
- David A Zuckerman
- Center for Bioethics, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital, Harvard Medical School, Charlestown, Massachusetts, USA.,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Huovinen A, Marinkovic I, Isokuortti H, Korvenoja A, Mäki K, Nybo T, Raj R, Melkas S. Traumatic Microbleeds in Mild Traumatic Brain Injury Are Not Associated with Delayed Return to Work or Persisting Post-Concussion Symptoms. J Neurotrauma 2021; 38:2400-2406. [PMID: 33847170 DOI: 10.1089/neu.2021.0055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The main objective of this prospective cohort study was to evaluate whether traumatic microbleeds (TMBs) are a significant prognostic factor of return to work (RTW), post-traumatic symptoms, and overall recovery in patients with mild traumatic brain injury (mTBI). One hundred and thirteen patients with mTBI were recruited from the Helsinki University Hospital emergency units. All patients underwent multi-contrast 3T magnetic resonance imaging (MRI) 3-17 days after mTBI. Patients were evaluated in the Traumatic Brain Injury Outpatient Clinic of Helsinki University Hospital 1 month after injury. Post-concussion symptoms were assessed with the Post-Concussion Symptom Questionnaire (RPQ) and overall recovery was assessed with the Glasgow Outcome Scale Extended (GOS-E). Their time to RTW was continuously measured up to 1 year after TBI. Median RTW was 9 days (interquartile range [IQR] 4-30) after mTBI and full RTW rate after 1 year was 98%. Patients with TMBs (n = 22) did not have more post-concussion symptoms (median RPQ 10.0 vs. 7.0, p = 0.217) or worse overall recovery (58% vs. 56% with GOS-E = 8, p = 0.853) than patients without TMBs (n = 91). There was no significant difference in time to RTW (13.5 vs. 7.0 days, p = 0.063). In this study, patients with TMBs did not have delayed RTW or more post-concussion symptoms than other patients with mTBI. TMBs in mTBI do not seem to be a significant prognostic factor of RTW.
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Affiliation(s)
- Antti Huovinen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ivan Marinkovic
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harri Isokuortti
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Antti Korvenoja
- Department of HUS Medical Imaging Center, Radiology, and Departments of University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Kaisa Mäki
- Department of Neuropsychology and University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Taina Nybo
- Department of Neuropsychology and University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Susanna Melkas
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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11
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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12
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Rabinstein AA. Good Recovery Is Possible in Young Patients With Posttraumatic Coma and Brainstem Microbleeds. Neurology 2021; 97:53-54. [PMID: 34050008 DOI: 10.1212/wnl.0000000000012197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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13
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Rauen K, Reichelt L, Probst P, Schäpers B, Müller F, Jahn K, Plesnila N. Quality of life up to 10 years after traumatic brain injury: a cross-sectional analysis. Health Qual Life Outcomes 2020; 18:166. [PMID: 32498679 PMCID: PMC7271485 DOI: 10.1186/s12955-020-01391-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Accepted: 05/05/2020] [Indexed: 01/15/2023] Open
Abstract
Background Traumatic brain injury (TBI) is the leading cause of death and disability among children and young adults in industrialized countries, but strikingly little is known how patients cope with the long-term consequences of TBI. Thus, the aim of the current study was to elucidate health-related quality of life (HRQoL) and outcome predictors in chronic TBI adults. Methods In this cross-sectional study, 439 former patients were invited to report HRQoL up to 10 years after mild, moderate or severe TBI using the QOLIBRI (Quality of Life after Brain Injury) questionnaire. The QOLIBRI total score has a maximum score of 100. A score below 60 indicates an unfavorable outcome with an increased risk of an affective and/or anxiety disorder. Results were correlated with demographics and basic characteristics received from medical records (TBI severity, etiology, age at TBI, age at survey, time elapsed since TBI, and sex) using regression models. Differences were considered significant at p < 0.05. Results From the 439 invited patients, 135 out of 150 in principle eligible patients (90%) completed the questionnaire; 76% were male, and most patients experienced severe TBI due to a traffic-related accident (49%) or a fall (44%). The mean QOLIBRI total score was 65.5 (± 22.6), indicating good HRQoL. Factors for higher level of satisfaction (p = 0.03; adjusted R2 = 0.1) were autonomy in daily life (p = 0.03; adjusted R2 = 0.09) and cognition (p = 0.05; adjusted R2 = 0.05). HRQoL was weakly correlated with initial TBI severity (p = 0.04; adjusted R2 = 0.02). 36% of patients reported unfavorable HRQoL with increased risk of one (20%) or two (16%) psychiatric disorders. Conclusions The majority of chronic TBI patients reported good HRQoL and the initial TBI severity is a slight contributor but not a strong predictor of HRQoL. Autonomy and cognition are decisive factors for satisfied outcome and should be clearly addressed in neurorehabilitation. One third of patients, however, suffer from unsatisfactory outcome with psychiatric sequelae. Thus, an early neuropsychiatric assessment after TBI is necessary and need to be installed in future TBI guidelines.
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Affiliation(s)
- Katrin Rauen
- Schoen Clinic Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany. .,Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center, Feodor-Lynen-Straße 17, 81377, Munich, Germany. .,Department of Geriatric Psychiatry, University Hospital of Psychiatry Zurich & Institute for Regenerative Medicine (IREM), University of Zurich, Minervastrasse 145, 8032, Zurich, Switzerland.
| | - Lara Reichelt
- Schoen Clinic Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany.,Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center, Feodor-Lynen-Straße 17, 81377, Munich, Germany
| | - Philipp Probst
- Institute for Medical Informatics, Biometry and Epidemiology (IBE), University of Munich, Munich, Germany
| | - Barbara Schäpers
- Schoen Clinic Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany
| | - Friedemann Müller
- Schoen Clinic Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany
| | - Klaus Jahn
- Schoen Clinic Bad Aibling, Kolbermoorer Strasse 72, 83043, Bad Aibling, Germany.,German Center for Vertigo and Balance Disorders, University of Munich Medical Center, Munich, Germany
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD), University of Munich Medical Center, Feodor-Lynen-Straße 17, 81377, Munich, Germany.,Munich Cluster for Systems Neurology (Synergy), Munich, Germany
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14
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The patient with severe traumatic brain injury: clinical decision-making: the first 60 min and beyond. Curr Opin Crit Care 2020; 25:622-629. [PMID: 31574013 DOI: 10.1097/mcc.0000000000000671] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW There is an urgent need to discuss the uncertainties and paradoxes in clinical decision-making after severe traumatic brain injury (s-TBI). This could improve transparency, reduce variability of practice and enhance shared decision-making with proxies. RECENT FINDINGS Clinical decision-making on initiation, continuation and discontinuation of medical treatment may encompass substantial consequences as well as lead to presumed patient benefits. Such decisions, unfortunately, often lack transparency and may be controversial in nature. The very process of decision-making is frequently characterized by both a lack of objective criteria and the absence of validated prognostic models that could predict relevant outcome measures, such as long-term quality and satisfaction with life. In practice, while treatment-limiting decisions are often made in patients during the acute phase immediately after s-TBI, other such severely injured TBI patients have been managed with continued aggressive medical care, and surgical or other procedural interventions have been undertaken in the context of pursuing a more favorable patient outcome. Given this spectrum of care offered to identical patient cohorts, there is clearly a need to identify and decrease existing selectivity, and better ascertain the objective criteria helpful towards more consistent decision-making and thereby reduce the impact of subjective valuations of predicted patient outcome. SUMMARY Recent efforts by multiple medical groups have contributed to reduce uncertainty and to improve care and outcome along the entire chain of care. Although an unlimited endeavor for sustaining life seems unrealistic, treatment-limiting decisions should not deprive patients of a chance on achieving an outcome they would have considered acceptable.
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15
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van Eijck MM, Herklots MW, Peluso J, Schoonman GG, Oldenbeuving AW, de Vries J, van der Naalt J, Roks G. Accuracy in prediction of long-term functional outcome in patients with traumatic axonal injury: a comparison of MRI scales. Brain Inj 2020; 34:595-601. [DOI: 10.1080/02699052.2020.1741683] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Marleen Maria van Eijck
- Department of Trauma TopCare, ETZ Hospital, Tilburg, The Netherlands
- Department of Neurology, ETZ Hospital, Tilburg, The Netherlands
| | | | - Jo Peluso
- Department of Radiology, ETZ Hospital, Tilburg, The Netherlands
| | | | | | - Jolanda de Vries
- Department of Trauma TopCare, ETZ Hospital, Tilburg, The Netherlands
- CoRPS, Department of Medical and Clinical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Joukje van der Naalt
- Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gerwin Roks
- Department of Trauma TopCare, ETZ Hospital, Tilburg, The Netherlands
- Department of Neurology, ETZ Hospital, Tilburg, The Netherlands
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16
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Reliability of Magnetic Resonance Tractography in Predicting Early Clinical Improvements in Patients with Diffuse Axonal Injury Grade III. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2019; 1251:19-28. [DOI: 10.1007/5584_2019_445] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
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