The management of severe traumatic brain injury in the initial postinjury hours - current evidence and controversies

Evaluating a Nurse-Driven Protocol for Indwelling Bladder Catheter Removal in Patients With Traumatic Brain Injury

INTRODUCTION

Catheter-associated urinary tract infections (CAUTIs) are common complications in patients with traumatic brain injury (TBI) who require indwelling bladder catheters (IBCs). This study examined the impact of an Acute Urinary Retention Algorithm (AURA) nursing protocol that incorporates intermittent catheterization (IC) on CAUTI incidence.

METHODS

A retrospective analysis was conducted on TBI patients with IBCs placed between 2018 and 2022 at a Level I trauma center in Southern California. Catheter-associated urinary tract infection incidence and catheter-associated complications were compared between patients treated with and without the AURA protocol.

RESULTS

Among 73,005 patients with IBC, 255 had TBI and were admitted to the intensive care unit. Only 27 (10.6%) patients had catheters removed through the AURA protocol and had longer dwell times than the nonprotocol patients (2.59 vs. 2.44 days, p < .001). Catheter-associated urinary tract infection incidence was statistically similar between the protocol (7.4%) and nonprotocol groups (3.5%) (p = .327). However, patients who developed CAUTI were more likely to have undergone more than one IC.

CONCLUSIONS

Timely removal of IBCs is crucial to minimizing the risk of CAUTI. This study highlights the underutilization of nurse-driven protocols such as AURA and suggests a careful application of IC in such protocols because of its potential association with increased CAUTI risk.

Comparative Efficacy and Safety of External Ventricular Drains and Intraparenchymal Pressure Monitors for Intracranial Pressure Monitoring in Traumatic Brain Injury: A Systematic Review and Meta-analysis

In the management of traumatic brain injury (TBI), intracranial pressure monitoring (ICPm) is crucial for the timely management of severe cases that show rapid neurological deterioration. External ventricular drains (EVDs) and intraparenchymal pressure monitors (IPMs) are the primary methods used in this setting; however, the debate over their comparative efficacy persists, primarily because of reliance on observational study data. This underscores the need for a meta-analysis to guide clinical decision-making. This study-level meta-analysis aims to assess and compare the efficacy and safety of EVDs versus IPMs in the management of TBI. A database search was conducted until February 13, 2024, to identify studies reporting clinical outcomes of patients with TBI who underwent ICPm with either EVD or IPM. Primary outcomes included mortality, ICPm duration, length of stay, and complications. From an initial pool of 537 articles, eight studies (six retrospective cohort studies and two prospective cohort studies), encompassing 7080 patients, met our inclusion criteria. Mortality rates showed no significant difference between groups (risk ratio 1.11 [95% confidence interval (CI) 0.86 to 1.42], p = 0.42). Patients monitored with IPM had shorter intensive care unit length of stay (mean difference 0.90 [95% CI 0.21 to 1.59], p = 0.01) and ICPm duration (mean difference 0.79 [95% CI 0.33 to 1.24], p = 0.0007), with a higher risk of requiring surgical decompression. Monitoring-related complications were similar across the two groups. Our findings suggest that EVD and IPM provide similar outcomes in terms of mortality. However, IPM may offer significant advantages in reducing the duration of ICPm and intensive care unit length of stay. EVD may be preferable for certain mid-term to long-term monitoring. The predominance of observational studies in the current literature highlights the need for further clinical trials to compare these interventions.

Unravelling Secondary Brain Injury: Insights from a Human-Sized Porcine Model of Acute Subdural Haematoma

Traumatic brain injury (TBI) remains one of the leading causes of death. Because of the individual nature of the trauma (brain, circumstances and forces), humans experience individual TBIs. This makes it difficult to generalise therapies. Clinical management issues such as whether intracranial pressure (ICP), cerebral perfusion pressure (CPP) or decompressive craniectomy improve patient outcome remain partly unanswered. Experimental drug approaches for the treatment of secondary brain injury (SBI) have not found clinical application. The complex, cellular and molecular pathways of SBI remain incompletely understood, and there are insufficient experimental (animal) models that reflect the pathophysiology of human TBI to develop translational therapeutic approaches. Therefore, we investigated different injury patterns after acute subdural hematoma (ASDH) as TBI in a post-hoc approach to assess the impact on SBI in a long-term, human-sized porcine TBI animal model. Post-mortem brain tissue analysis, after ASDH, bilateral ICP, CPP, cerebral oxygenation and temperature monitoring, and biomarker analysis were performed. Extracerebral, intraparenchymal-extraventricular and intraventricular blood, combined with brainstem and basal ganglia injury, influenced the experiment and its outcome. Basal ganglia injury affects the duration of the experiment. Recognition of these different injury patterns is important for translational interpretation of results in this animal model of SBI after TBI.

Omega-3 Fatty Acids and Traumatic Injury in the Adult and Immature Brain

Background/Objectives: Traumatic brain injury (TBI) can lead to substantial disability and health loss. Despite its importance and impact worldwide, no treatment options are currently available to help protect or preserve brain structure and function following injury. In this review, we discuss the potential benefits of using omega-3 polyunsaturated fatty acids (O3 PUFAs) as therapeutic agents in the context of TBI in the paediatric and adult populations. Methods: Preclinical and clinical research reports investigating the effects of O3 PUFA-based interventions on the consequences of TBI were retrieved and reviewed, and the evidence presented and discussed. Results: A range of animal models of TBI, types of injury, and O3 PUFA dosing regimens and administration protocols have been used in different strategies to investigate the effects of O3 PUFAs in TBI. Most evidence comes from preclinical studies, with limited clinical data available thus far. Overall, research indicates that high O3 PUFA levels help lessen the harmful effects of TBI by reducing tissue damage and cell loss, decreasing associated neuroinflammation and the immune response, which in turn moderates the severity of the associated neurological dysfunction. Conclusions: Data from the studies reviewed here indicate that O3 PUFAs could substantially alleviate the impact of traumatic injuries in the central nervous system, protect structure and help restore function in both the immature and adult brains.

Contusion expansion, low platelet count and bifrontal contusions are associated with worse patient outcome following traumatic brain injury-a retrospective single-center study

BACKGROUND

Cortical contusions are common in moderate-severe traumatic brain injury (TBI). Cortical contusions often expand, potentially causing neuro-worsening several hours to days post-trauma. While contusion expansion (CE) may affect outcome, potential clinical and radiological markers that can predict CE have been insufficiently explored. In the present single-center retrospective observational cohort study, we evaluated clinical outcome by the Glasgow Outcome Scale extended (GOSE) scale and evaluated risk factor for CE.

METHOD

Adult TBI patients > 18 years of age, and of all injury severities, were included. Main variables of interest were low platelet count, defined as < 150 × 109/L, presence of bifrontal contusions and CE, defined as absolute contusion volume increase in cm3. Factors associated with CE and clinical outcome according to GOSE were analyzed.

RESULTS

Between 2012-2022, 272 patients were included. Contusion size on admission correlated positively with CE, as did the Marshall and Rotterdam radiological classification scores. Bifrontal contusions were significantly larger at admission, experienced larger CE, and had a worse outcome than contusions in other locations. Patients with a platelet count < 150 × 109/L experienced a greater volume CE and had a worse outcome when compared to patients with a normal platelet count. In a multivariate analysis, CE remained significantly associated with a poor outcome six months post- injury.

CONCLUSION

Contusion volume at admission, Marshall CT classification and Rotterdam CT score, positively correlated to CE. Bifrontal contusions and a platelet count < 150 × 109/L were associated with CE, and a poor clinical outcome. Large CE volumes were associated with a worse clinical outcome, and CE was per se associated with outcome in a multivariate analysis. Management of these risk factors for CE in the acute post-injury setting may be needed to attenuate contusion expansion and to improve clinical outcome in TBI patients suffering from cortical contusion injuries.

Cerebral contusions - Pathomechanism, predictive factors for progression and historical and current management

Introduction

Cerebral contusions (CCs) are common traumatic brain injuries known for their propensity to progress. Understanding their mechanical pathogenesis and predictive factors for progression is crucial for optimal management.

Research question

To provide an overview of current knowledge on CCs, including pathomechanisms, predictive factors of contusion progression, and management strategies.

Material and methods

A literature search was conducted using PubMed, Scopus and ISI web of knowledge focused on articles in English with the words "cerebral contusion" together with the words "traumatic brain injury", "pathomechanism", "progression of contusion", "predictive factors" and "management" alone or in combination.

Results

The management of CCs has evolved alongside the advances in neurointensive care, yet there is no consensus. Evidence on the effectiveness of early surgery, importantly, for the group which has the potential to expand, is limited. Some predictive factors for contusion progression have been identified, including age, injury mechanism, coagulopathy and initial contusion volume which could help to guide decision-making.

Discussion and conclusion

While various theories exist on pathomechanisms and several predictive factors for progression have been proposed, consensus on optimal management remains elusive. Individualized care guided by the predictive factors is essential. Challenges posed by antithrombotic medications highlight the need for early intervention strategies.Decompressive craniectomy could serve as a potential tool in severe traumatic brain injury management including contusions. Conducting large cohort studies to refine predictive models and harmonizing management approaches would help to improve outcomes of patients with CCs.

The Current Update of Conventional and Innovative Treatment Strategies for Central Nervous System Injury

This review explores the complex challenges and advancements in the treatment of traumatic brain injury (TBI) and spinal cord injury (SCI). Traumatic injuries to the central nervous system (CNS) trigger intricate pathophysiological responses, frequently leading to profound and enduring disabilities. This article delves into the dual phases of injury-primary impacts and the subsequent secondary biochemical cascades-that worsen initial damage. Conventional treatments have traditionally prioritized immediate stabilization, surgical interventions, and supportive medical care to manage both the primary and secondary damage associated with central nervous system injuries. We explore current surgical and medical management strategies, emphasizing the crucial role of rehabilitation and the promising potential of stem cell therapies and immune modulation. Advances in stem cell therapy, gene editing, and neuroprosthetics are revolutionizing treatment approaches, providing opportunities not just for recovery but also for the regeneration of impaired neural tissues. This review aims to emphasize emerging therapeutic strategies that hold promise for enhancing outcomes and improving the quality of life for affected individuals worldwide.

Neurosurgical intervention in ultra-severe closed traumatic brain injury: Is it worth the effort?

Introduction

A subgroup of severe Traumatic Brain Injury (TBI) patients, known as ultra-severe (us-TBI), is most commonly defined as a post-resuscitation Glasgow Coma Scale (GCS) of 3-5. There is uncertainty on whether these critically injured patients can benefit from neurosurgical intervention.

Research question

The available evidence regarding the decision-making and outcome following management of us-TBI patients is critically reviewed.

Material and methods

Selected databases (PubMed, Google Scholar, Scopus and Cochrane Library) were searched from 1979 to May 2024 for publications on us-TBI patients, with a focus on treatment strategy, mortality and functional outcomes. Inclusion criteria were adult patients >18 years old with closed head trauma and admission post-resuscitation GCS 3-5. Studies were independently assessed for inclusion by two reviewers, and potential disagreements were solved by consensus.

Results

Where such data could be extracted, mortality rate was 27-100%, and favorable outcome was observed in 4-30% of us-TBI patients. While early aggressive neurosurgical management was associated with decreased mortality, a high proportion of patients survived with unfavorable functional status.

Discussion and conclusion

With supportive care only, outcome of patients with us-TBI is almost universally poor. Early and aggressive neurosurgical intervention in addition to best medical management can lead to favorable functional outcome in selected cases particularly in younger patients with an initial GCS>3 and traumatic mass lesions. There is insufficient data regarding the effectiveness of neurosurgical management on the outcome of us-TBI patients. and the decision to initiate treatment should be based on an individual basis.

An injectable refrigerated hydrogel for inducing local hypothermia and neuroprotection against traumatic brain injury in mice

BACKGROUND

Hypothermia is a promising therapy for traumatic brain injury (TBI) in the clinic. However, the neuroprotective outcomes of hypothermia-treated TBI patients in clinical studies are inconsistent due to several severe side effects. Here, an injectable refrigerated hydrogel was designed to deliver 3-iodothyronamine (T1AM) to achieve a longer period of local hypothermia for TBI treatment. Hydrogel has four advantages: (1) It can be injected into injured sites after TBI, where it forms a hydrogel and avoids the side effects of whole-body cooling. (2) Hydrogels can biodegrade and be used for controlled drug release. (3) Released T1AM can induce hypothermia. (4) This hydrogel has increased medical value given its simple operation and ability to achieve timely treatment.

METHODS

Pol/T hydrogels were prepared by a low-temperature mixing method and characterized. The effect of the Pol/T hydrogel on traumatic brain injury in mice was studied. The degradation of the hydrogel at the body level was observed with a small animal imager. Brain temperature and body temperature were measured by brain thermometer and body thermometer, respectively. The apoptosis of peripheral nerve cells was detected by immunohistochemical staining. The protective effect of the hydrogels on the blood-brain barrier (BBB) after TBI was evaluated by the Evans blue penetration test. The protective effect of hydrogel on brain edema after injury in mice was detected by Magnetic resonance (MR) in small animals. The enzyme linked immunosorbent assay (ELISA) method was used to measure the levels of inflammatory factors. The effects of behavioral tests on the learning ability and exercise ability of mice after injury were evaluated.

RESULTS

This hydrogel was able to cool the brain to hypothermia for 12 h while maintaining body temperature within the normal range after TBI in mice. More importantly, hypothermia induced by this hydrogel leads to the maintenance of BBB integrity, the prevention of cell death, the reduction of the inflammatory response and brain edema, and the promotion of functional recovery after TBI in mice. This cooling method could be developed as a new approach for hypothermia treatment in TBI patients.

CONCLUSION

Our study showed that injectable and biodegradable frozen Pol/T hydrogels to induce local hypothermia in TBI mice can be used for the treatment of traumatic brain injury.

Trauma systems in high socioeconomic index countries in 2050

Considerable political, structural, environmental and epidemiological change will affect high socioeconomic index (SDI) countries over the next 25 years. These changes will impact healthcare provision and consequently trauma systems. This review attempts to anticipate the potential impact on trauma systems and how they could adapt to meet the changing priorities. The first section describes possible epidemiological trajectories. A second section exposes existing governance and funding challenges, how these can be met, and the need to incorporate data and information science into a learning and adaptive trauma system. The last section suggests an international harmonization of trauma education to improve care standards, optimize immediate and long-term patient needs and enhance disaster preparedness and crisis resilience. By demonstrating their capacity for adaptation, trauma systems can play a leading role in the transformation of care systems to tackle future health challenges.