Linking the chain of survival: trauma as a traditional role model for multisystem trauma and brain injury:

Acute Extra-Arachnoid Subdural Hematomas in Patients 50 Years and Older: When Subdurals Act Like Epidurals

BACKGROUND

Some patients with subdural hematoma (SDH) with acute extra-arachnoid lesions and without concomitant subarachnoid blood or contusions may present in similarly grave neurological condition compared with the general population of patients with SDH. However, these patients often make an impressive neurological recovery. This study compared neurological outcomes in patients with extra-arachnoid SDH with all other SDH patients.

METHODS

We compared a prospective series of extra-arachnoid SDH patients without subarachnoid hemorrhage or other concomitant intracranial injury with a Transforming Research and Clinical Knowledge in TBI control group with SDH only. We performed inverse probability weighting for key characteristics and ordinal regression with and without controlling for midline shift comparing neurological outcomes (Extended Glasgow Outcome Scale score) at 2 weeks. We used the Corticosteroid Randomization After Significant Head Injury prognostic model to predict mortality based on age, Glasgow Coma Scale score, pupil reactivity, and major extracranial injury.

RESULTS

Mean midline shift was significantly different between extra-arachnoid SDH and control groups (7.2 mm vs. 2.7 mm, P < 0.001). After weighting for group allocation and controlling for midline shift, extra-arachnoid SDH patients had 5.68 greater odds (P < 0.001) of a better 2-week Extended Glasgow Outcome Scale score than control patients. Mortality in the extra-arachnoid SDH group was less than predicted by the Corticosteroid Randomization After Significant Head Injury prognostic model (10% vs. 21% predicted).

CONCLUSIONS

Patients with extra-arachnoid SDH have significantly better 2-week neurological outcomes and lower mortality than predicted by the Corticosteroid Randomization After Significant Head Injury model. Neurosurgeons should consider surgery for this patient subset even in cases of poor neurological examination, older age, and large hematoma with high degree of midline shift.

Mobile Smartphone-Based Digital Pupillometry Curves in the Diagnosis of Traumatic Brain Injury

Objective

The pupillary light reflex (PLR) and the pupillary diameter over time (the PLR curve) is an important biomarker of neurological disease, especially in the diagnosis of traumatic brain injury (TBI). We investigated whether PLR curves generated by a novel smartphone pupillometer application could be easily and accurately interpreted to aid in the diagnosis of TBI.

Methods

A total of 120 PLR curves from 42 healthy subjects and six patients with TBI were generated by PupilScreen. Eleven clinician raters, including one group of physicians and one group of neurocritical care nurses, classified 48 randomly selected normal and abnormal PLR curves without prior training or instruction. Rater accuracy, sensitivity, specificity, and interrater reliability were calculated.

Results

Clinician raters demonstrated 93% accuracy, 94% sensitivity, 92% specificity, 92% positive predictive value, and 93% negative predictive value in identifying normal and abnormal PLR curves. There was high within-group reliability (k = 0.85) and high interrater reliability (K = 0.75).

Conclusion

The PupilScreen smartphone application-based pupillometer produced PLR curves for clinical provider interpretation that led to accurate classification of normal and abnormal PLR data. Interrater reliability was greater than previous studies of manual pupillometry. This technology may be a good alternative to the use of subjective manual penlight pupillometry or digital pupillometry.

Estimated incidence and case fatality rate of traumatic brain injury among children (0-18 years) in Sub-Saharan Africa. A systematic review and meta-analysis

INTRODUCTION

Studies from Sub-Saharan Africa (SSA) countries have reported on the incidence and case fatality rate of children with Traumatic Brain Injury (TBI). However, there is lack of a general epidemiologic description of the phenomenon in this sub-region underpinning the need for an accurate and reliable estimate of incidence and outcome of children (0-18 years) with TBI. This study therefore, extensively reviewed data to reliably estimate incidence, case fatality rate of children with TBI and its mechanism of injury in SSA.

METHODS

Electronic databases were systematically searched in English via Medline (PubMed), Google Scholar, and Africa Journal Online (AJOL). Two independent authors performed an initial screening of studies based on the details found in their titles and abstracts. Studies were assessed for quality/risk of bias using the modified Newcastle-Ottawa Scale (NOS). The pooled case fatality rate and incidence were estimated using DerSimonian and Laird random-effects model (REM). A sub-group and sensitivity analyses were performed. Publication bias was checked by the funnel plot and Egger's test. Furthermore, trim and fill analysis was used to adjust for publication bias using Duval and Tweedie's method.

RESULTS

Thirteen (13) hospital-based articles involving a total of 40685 participants met the inclusion criteria. The pooled case fatality rate for all the included studies in SSA was 8.0%; [95% CI: 3.0%-13.0%], and the approximate case fatality rate was adjusted to 8.2%, [95% CI:3.4%-13.0%], after the trim-and-fill analysis was used to correct for publication bias. A sub-group analysis of sub-region revealed that case fatality rate was 8% [95% CI: 2.0%-13.0%] in East Africa, 1.0% [95% CI: 0.1% -3.0%] in Southern Africa and 18.0% [95% CI: 6.0%-29.0%] in west Africa. The pooled incidence proportion of TBI was 18% [95% CI: 2.0%-33.0%]. The current review showed that Road Traffic Accident (RTA) was the predominant cause of children's TBI in SSA. It ranged from 19.1% in South Africa to 79.1% in Togo.

CONCLUSION

TBI affects 18% of children aged 0 to 18 years, with almost one-tenth dying in SSA. The most common causes of TBI among this population in SSA were RTA and falls. TBI incidence and case fatality rate of people aged 0-18 years could be significantly reduced if novel policies focusing on reducing RTA and falls are introduced and implemented in SSA.

Moderate and Severe Traumatic Brain Injury

PURPOSE OF REVIEW

Traumatic brain injury (TBI) encompasses a group of heterogeneous manifestations of a disease process with high neurologic morbidity and, for severe TBI, high probability of mortality and poor neurologic outcomes. This article reviews TBI in neurocritical care, hence focusing on moderate and severe TBI, and includes an up-to-date review of the many variables to be considered in clinical care.

RECENT FINDINGS

With advances in medicine and biotechnology, understanding of the impact of TBI has substantially elucidated the distinction between primary and secondary brain injury. Consequently, care of TBI is evolving, with intervention-based modalities targeting multiple physiologic variables. Multimodality monitoring to assess intracranial pressure, cerebral oxygenation, cerebral metabolism, cerebral blood flow, and autoregulation is at the forefront of such advances.

SUMMARY

Understanding the anatomic and physiologic principles of acute brain injury is necessary in managing moderate to severe TBI. Management is based on the prevention of secondary brain injury from resultant trauma. Care of patients with TBI should occur in a dedicated critical care unit with subspecialty expertise. With the advent of multimodality monitoring and targeted biomarkers in TBI, patient outcomes have a higher probability of improving in the future.

Real-Time Intraoperative Pressure Monitoring to Avoid Surgically Induced Localized Brain Injury Using a Miniaturized Piezoresistive Pressure Sensor

Neurosurgical procedures often cause damage to the brain tissue at the periphery from surgical manipulations. Especially during retraction, a large amount of pressure could be applied on the brain surface, which can damage it, leading to brain herniation, which can be fatal for patients. To resolve this issue, we have developed a pressure sensor that can be used to monitor the applied pressure during surgery for intraoperative care. This device was tested on a rodent model to create a superficial surgically induced damage profile for three different applied pressures (30, 50, and 70 mmHg) and compared to a standard intracranial pressure monitoring system. Magnetic resonance imaging has been performed after surgical procedures to detect the herniation caused by applied pressure. To evaluate the damage to brain cells and tissue rupture, histological analysis was performed using hematoxylin and eosin staining. A scoring system was developed to understand the severity of the surgically induced brain injury, which will help neurosurgeons to limit the pressure to an optimum point without causing damage.

Evaluation of serum pannexin-1 as a prognostic biomarker for traumatic brain injury

BACKGROUND

Pannexin-1 is a type of hexameric plasma membrane channel-forming proteins, and plays a significant role in brain injury. We investigated the potential prognostic value of pannexin-1 in traumatic brain injury.

METHODS

A single peripheral blood sample in 112 patients with severe traumatic brain injury and 112 controls was prospectively collected for subsequent measurement of serum pannexin-1. Clinical follow-up was performed at 6 months. An unfavorable outcome was defined as Glasgow Outcome Scale score of 1-3.

RESULTS

The patients showed markedly higher serum pannexin-1 concentrations than the controls. Among the patients, pannexin-1 concentrations were significantly and negatively correlated with Glasgow coma scale scores. On receiver operating characteristic curve analysis, the predictive value in terms of area under the curve was substantially high for serum pannexin-1 as a predictor for both 6-month mortality and unfavorable outcome. Regression analyses confirmed that there was an increased risk of either 6-month mortality, overall survival or unfavorable outcome associated with serum pannexin-1 concentrations after adjusting for possible confounders.

CONCLUSIONS

Serum pannexin-1 may represent a potential prognostic biomarker for head trauma.

Epidemiology, Management, and Functional Outcomes of Traumatic Brain Injury in Sub-Saharan Africa

BACKGROUND

Trauma accounts for 4.7 million deaths each year, with an estimated 90% of these occurring in low- and middle-income countries (LMICs). Approximately half of trauma-related deaths are caused by central nervous system injury. Because a thorough understanding of traumatic brain injury (TBI) in LMICs is essential to mitigate TBI-related mortality, we established a clinical and radiographic database to characterize TBI in our low-income setting.

METHODS

This is a review of prospectively collected data from Kamuzu Central Hospital, a tertiary care center in the capital of Malawi. All patients admitted from October 2016 through May 2017 with a history of head trauma, altered consciousness, and/or radiographic evidence TBI were included. We performed descriptive statistics, a Cox regression analysis, and a survival analysis.

RESULTS

There were 280 patients who met inclusion criteria; of these, 80.5% were men. The mean age was 28.8 ± 16.3 years. Median Glasgow Coma Scale (GCS) score was 12 (interquartile range, 8-15). Road traffic crashes constituted the most common injury mechanism (60.7%). There were 148 (52.3%) patients who received a computed tomography scan, with the most common findings being contusions (26.1%). Of the patients, 88 (33.0%) had severe TBI, defined as a GCS score ≤8, of whom 27.6% were intubated and 10.3% received tracheostomies. Overall mortality was 30.9%. Of patients who survived, 80.1% made a good recovery. Female sex was protective, and the only significant predictor of poor functional outcome was presence of severe TBI (hazard ratio, 2.98; 95% confidence interval, 1.79-4.95).

CONCLUSIONS

TBI represents a significant part of the global neurosurgical burden of disease. Implementation of proven in-hospital interventions for these patients is critical to attenuate TBI-related morbidity and mortality.

Outcomes Following Exploratory Burr Holes for Traumatic Brain Injury in a Resource Poor Setting

BACKGROUND

Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. The incidence of TBI in low- and middle-income countries (LMICs) is disproportionately high, with an associated increased risk of mortality from TBI relative to high-income countries. Although computed tomography is the diagnostic method of choice, this is often unavailable in LMICs. Exploratory burr holes may provide a suitable choice for diagnosis and treatment of TBI.

METHODS

We performed a retrospective review of prospectively collected data at KCH, a tertiary care center in Lilongwe, Malawi. All trauma patients presenting between June 2012 and July 2015 with a deteriorating level of consciousness and localizing signs and who underwent exploratory burr holes were included. Additionally, we included all patients admitted with TBI, requiring higher-level care during 2011. No patients underwent exploratory burr hole during this time. We performed logistic regression to identify predictors of mortality in the total population of TBI patients.

RESULTS

Among the 241 patients who presented to KCH with TBI requiring higher-level care, the total mortality was 16.4%. More than half (163, or 68%) underwent exploratory burr hole with a mortality of 6.8%. Mortality in patients who did not undergo exploratory burr hole was 43.9%. Upon adjusted logistic regression, not undergoing exploratory burr hole significantly increased the odds of mortality (odds ratio = 12.0, P = 0.000, 95% confidence interval = 4.48-31.9).

CONCLUSION

Exploratory burr holes remain an important diagnostic and therapeutic procedure for TBI in LMICs. Exploratory burr hole technique should be integrated into general surgery education to attenuate TBI-related mortality.

The effect of anatomic location of injury on mortality risk in a resource-poor setting

INTRODUCTION

Injury is a significant cause of death, with approximately 4.7 million people mortalities each year. By 2030, injury is predicted to be among the top 20 causes of death worldwide. We sought to characterize and compare the mortality probability in trauma patients in a resource-poor setting based on anatomic location of injury.

METHODS

We performed a retrospective analysis of prospectively collected data using the trauma database at Kamuzu Central Hospital (KCH) in Lilongwe, Malawi. We included all adult trauma patients (≥16years) admitted between 2011 and 2015. We stratified patients according to anatomic location of injury, and used descriptive statistics to compare characteristics and management of each group. Bivariate analysis by mortality was done to determine covariates for our adjusted model. A Cox proportional hazard model was performed, using upper extremity injury as the baseline comparator. Descriptive statistics were used to describe the trend in incidence and mortality of head and spine injuries over five years.

RESULTS

Of the 76,984 trauma patients who presented to KCH from 2011 to 2015, 49,126 (63.8%) were adults, and 8569 (17.4%) were admitted. The most common injury was to the head or spine, seen in 3712 patients (43.6%). The highest unadjusted hazard ratio for mortality was in head and spine injury patients, at 3.685 (95% CI=2.50-5.44), which increased to 4.501 (95% CI=2.78-7.30) when adjusted for age, sex, injury severity, transfer status, injury mechanism, and surgical intervention. Abdominal trauma had the second highest adjusted hazard of mortality, at 3.62 (95% CI=1.92-6.84) followed by thoracic trauma (HR=1.3621, 95% CI=0.49-3.56).

CONCLUSION

In our setting, head or spine injury significantly increases the hazard of mortality significantly compared to all other anatomic injury locations. The prioritization of timely operative and non-operative head injury management is imperative. The development of head injury units may help attenuate trauma- related mortality in resource poor settings.

Serum macrophage migration inhibitory factor concentrations correlate with prognosis of traumatic brain injury

BACKGROUND

Macrophage migration inhibitory factor (MIF) is a well-known pro-inflammatory cytokine. Serum MIF concentrations are associated with the severity and prognosis of ischemic stroke.

METHODS

In this prospective, observational study, white blood cell (WBC) count and serum concentrations of C-reactive protein (CRP), interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α) and MIF among 108 severe traumatic brain injury (TBI) patients and 108 controls were measured. We determined whether serum MIF concentrations are associated with inflammation, severity, in-hospital major adverse events (IMAEs) (i.e., in-hospital mortality, acute lung injury, acute traumatic coagulopathy, progressive hemorrhagic injury and posttraumatic cerebral infarction) and long-term clinical outcome (i.e., 6-month functional outcome) after TBI.

RESULTS

As compared to the controls, serum CRP, IL-6, TNF-α and MIF concentrations were significantly increased. MIF concentrations correlated with WBC count, CRP, IL-6 and TNF-α concentrations and Glasgow coma scale (GCS) scores. MIF in serum was independently associated with IMAEs and long-term clinical outcome. Area under receiver operating characteristic curve of MIF concentrations was similar to GCS scores'. Moreover, MIF concentrations markedly improved the predictive value of GCS scores for 6-month unfavorable outcome.

CONCLUSION

Increased serum MIF concentrations have close relation to inflammation, trauma severity and clinical outcomes, substantializing MIF as a good prognostic biomarker after TBI.

Epidemiology and Characteristics of Neurosurgical Conditions at Mbarara Regional Referral Hospital

BACKGROUND

The unmet surgical need, specifically neurosurgical need, in Uganda is significant, yet only 2 public hospitals currently perform neurosurgery in the country. This study examines the epidemiology and outcomes of neurosurgical conditions presenting to 1 of 12 regional referral hospitals in Uganda, in an effort to understand the neurosurgical needs of this population.

METHODS

The study was conducted at Mbarara Regional Referral Hospital (MRRH), in southwestern Uganda. Demographics, clinical characteristics, and outcomes were retrospectively collected for all patients who presented to MRRH with a neurosurgical condition between January 2012 and September 2015.

RESULTS

During the study period, 1854 patients presented to MRRH with a neurosurgical condition. More than half of the patients were between 19 and 40 years old, and the majority were males (76.1%). The overall median length of stay was 5 days (interquartile range: 2.5-10). The majority of admissions were due to trauma (87%), with almost 60% due to road traffic incidents. The overall mortality rate was 12.8%. A multivariable Cox proportional hazards model revealed that age, closed head injury, and admission Glasgow Coma Scale have a strong positive correlation with mortality while getting a diagnostic image and neurosurgical procedure were negatively correlated with mortality.

CONCLUSION

Traumatic brain injury represented the majority of neurosurgical admissions at MRRH, disproportionately affecting young males. Age, closed head injury, admission Glasgow Coma Scale, getting a diagnostic image, and neurosurgical procedure were all independent predictors of mortality. Resource appropriate interventions throughout the health system are needed to meet the demand and improve outcomes.

Catecholaminergic based therapies for functional recovery after TBI

Among the many pathophysiologic consequences of traumatic brain injury are changes in catecholamines, including dopamine, epinephrine, and norepinephrine. In the context of TBI, dopamine is the one most extensively studied, though some research exploring epinephrine and norepinephrine have also been published. The purpose of this review is to summarize the evidence surrounding use of drugs that target the catecholaminergic system on pathophysiological and functional outcomes of TBI using published evidence from pre-clinical and clinical brain injury studies. Evidence of the effects of specific drugs that target catecholamines as agonists or antagonists will be discussed. Taken together, available evidence suggests that therapies targeting the catecholaminergic system may attenuate functional deficits after TBI. Notably, it is fairly common for TBI patients to be treated with catecholamine agonists for either physiological symptoms of TBI (e.g. altered cerebral perfusion pressures) or a co-occuring condition (e.g. shock), or cognitive symptoms (e.g. attentional and arousal deficits). Previous clinical trials are limited by methodological limitations, failure to replicate findings, challenges translating therapies to clinical practice, the complexity or lack of specificity of catecholamine receptors, as well as potentially counfounding effects of personal and genetic factors. Overall, there is a need for additional research evidence, along with a need for systematic dissemination of important study details and results as outlined in the common data elements published by the National Institute of Neurological Diseases and Stroke. Ultimately, a better understanding of catecholamines in the context of TBI may lead to therapeutic advancements. This article is part of a Special Issue entitled SI:Brain injury and recovery.

Outcomes of different health care contexts for direct transport to a trauma center versus initial secondary center care: a systematic review and meta-analysis

INTRODUCTION

Within a trauma system, pre-hospital care is the first step in managing the trauma patient. Timely and appropriate transport of the injured patient to the most appropriate facility is important. Many trauma systems mandate that serious trauma cases are transported directly to a level I trauma center unless transfer to a closer hospital is deemed necessary to resuscitate and stabilize the patient prior to onward transfer to definitive care. Statistical and clinical heterogeneity is often high and is likely to be influenced by the heath care context.

METHODS

We conducted a systematic review and meta-analysis to compare patient outcomes for patients with serious trauma transported directly to a Level I/II trauma center ('direct' group) to those transported to a healthcare facility before transfer to the Level I/ II trauma center ('transfer' group). A search of bibliographic databases and secondary sources that focus on trauma was made. Studies were grouped by region: United States of America, Canada, Europe, Asia, Australia and New Zealand and South Africa.

RESULTS

The review included 43,554 patients from the 30 studies that met the selection criteria. Heterogeneity of the studies was high (I(2) 71%) overall but low for European, Asian, and Australian and New Zealand studies. There was considerable variation between studies in the structure, policies and practices of the respective trauma systems. The effect of "directness" on patient outcomes was inconsistent.

CONCLUSION

The current research evidence does not support nor refute a position that all serious trauma patients be routinely transported directly to a level I/II trauma center. As this is a complex issue, local health-care context and injury profile influence trauma policy and practice.

Diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations performed by emergency medical technicians

OBJECTIVE

We aimed to assess the diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations when used by emergency medical technicians (EMTs) to detect the presence of free abdominal fluid.

METHODS

Six level 1 EMTs (similar to intermediate EMTs in the United States) who worked at a tertiary emergency department in Korea underwent an educational program consisting of two one-hour didactic lectures that included the principles of ultrasonography, the anatomy of the abdomen, and two hours of hands-on practice. After this educational session, the EMTs performed FAST examinations on a convenience sample of patients from July 1 to October 5, 2009. These patients also received an abdominal computed tomography (CT) scan regardless of their chief complaints. The CT findings served as the definitive standard and were interpreted routinely and independently by emergency radiologists who were blinded to the study protocol. In addition, the EMTs were blinded to the CT findings. A positive CT finding was defined as the presence of free fluid, as interpreted by the radiologist. The sensitivity, specificity, predictive values, and their 95% confidence intervals (CIs) were calculated. Informed consent was obtained from all participating patients.

RESULTS

Among the 1,060 eligible patients with abdominal CT scans, 403 patients were asked to participate in the study, and 240 patients agreed. Of these 240 patients, 80 (33.3%) had results showing the presence of free fluid. Fourteen patients had a significant amount of peritoneal cavity fluid, 15 had a moderate amount of peritoneal cavity fluid, and 51 had a minimal amount of peritoneal cavity fluid. Compared with the CT findings, the diagnostic performance of the FAST examination had a sensitivity of 61.3% (95% CI, 50.3%-71.2%), specificity of 96.3% (95% CI, 92.1%-98.3%), positive predictive value of 89.1% (95% CI, 77.0%-95.4%), and negative predictive value of 83.2% (95% CI, 76.9%-88.2%). For a significant or moderate amount of peritoneal cavity fluid, the sensitivity was considerably higher (86.2%).

CONCLUSION

EMTs in Korea showed a high diagnostic performance that was comparable to that of surgeons and physicians when detecting peritoneal cavity free fluid in a Korean emergency department setting. The validity of FAST examinations in prehospital care situations should be investigated further.

Access to trauma systems in Canada

BACKGROUND

Trauma is a leading cause of morbidity, potential years of life lost and health care expenditure in Canada and around the world. Trauma systems have been established across North America to provide comprehensive injury care and to lead injury control efforts. We sought to describe the current status of trauma systems in Canada and Canadians' access to acute, multidisciplinary trauma care.

METHODS

A national survey was used to identify the locations and capabilities of adult trauma centers across Canada and to identify the catchment populations they serve. Geographic information science methods were used to map the locations of Level I and Level II trauma centers and to define 1-hour road travel times around each trauma center. Data from the 2006 Canadian Census were used to estimate populations within and outside 1-hour access to definitive trauma care.

RESULTS

In Canada, 32 Level I and Level II trauma centers provide definitive trauma care and coordinate the efforts of their surrounding trauma systems. Most Canadians (77.5%) reside within 1-hour road travel catchments of Level I or Level II centers. However, marked geographic disparities in access persist. Of the 22.5% of Canadians who live more than an hour away from a Level I or Level II trauma centers, all are in rural and remote regions.

DISCUSSION

Access to high quality acute trauma care is well established across parts of Canada but a clear urban/rural divide persists. Regional efforts to improve short- and long-term outcomes after severe trauma should focus on the optimization of access to pre-hospital care and acute trauma care in rural communities using locally relevant strategies or novel care delivery options.

Towards brain first-aid: a diagnostic device for conscious awareness

When the brain is damaged, evaluating an individual's level of awareness can be a major diagnostic challenge (Is he or she in there?). Existing tests typically rely on behavioral indicators, which are incorrect in as many as one out of every two cases. The current paper presents a diagnostic device that addresses this problem. The technology circumvents behavioral limitations through noninvasive brain wave measurements (electroencephalography, or EEG). Unlike traditional EEG, the device is designed for point-of-care use by incorporating a portable, user-friendly, and stable design. It uses a novel software algorithm that automates subject stimulation, data acquisition/analysis, and the reporting of results. The test provides indicators for five identifiable levels of neural processing: sensation, perception, attention, memory, and language. The results are provided as rapidly obtained diagnostic, reliability, validity, and prognostic scores. The device can be applied to a wide variety of patients across a host of different environments. The technology is designed to be wireless-enabled for remote monitoring and assessment capabilities. In essence, the device is developed to scan for conscious awareness in order to optimize subsequent patient care.