The Infrascanner, a handheld device for screeningin situfor the presence of brain haematomas

Noninvasive Monitoring of Traumatic Intracranial Hematoma Progression Using the Infrascanner: Preliminary Experience

Objectives

Early detection of intracranial hematoma (ICH) expansion is critical to improving outcomes in patients with traumatic brain injuries (TBIs). The Infrascanner 2000 (InfraScan Inc) is a US Food and Drug Administration-cleared device capable of detecting ICHs. We report our preliminary experience of conducting a prospective evaluation of serial infrascans to evaluate the diagnostic performance of the device for monitoring changes in ICH size.

Methods

A single-center prospective observational study was conducted. We included patients with traumatic ICHs detected on admission computed tomography (CT) scanning, and conducted hourly infrascans until a second CT scan had been performed. We evaluated the practicability of enrollment, conducting hourly infrascans, and the diagnostic performance of the device.

Results

We approached 134 patients, or their legally authorized representatives, and enrolled 62 (46%). Most index hematomas were small (median, 2.5 mL, IQR, 0.6-7.0 mL), and 23 experienced enlargement. Hourly infrascan assessments were performed successfully in the majority of patients (300 of 340 scans, 88%). The most common reasons for scans not being performed, or not performed on time, were technical issues with the devices (17 scans, 40%), the presence of dressings and bandages (2 scans, 5%), and patients being taken for other investigations or treatment (12 scans, 31%). Given the sample size, the small size of enrolled patients' ICHs, and the low proportion that experienced enlargement, it was not possible to demonstrate the ability of the Infrascanner to detect expansion.

Conclusion

This preliminary study confirms the practicability of conducting a prospective evaluation of the Infrascanner for the purpose of serially monitoring the size of ICHs in trauma patients.

Evaluating performance of a near-infrared-spectroscopy-based and machine-learning-powered bio-optical sensitivity parameters in identifying intracranial hemorrhages in TBI across different age-groups

PRIMARY OBJECTIVE

To evaluate the accuracy of an innovative machine-learning-powered near-infrared spectroscopy (mNIRS)-based bio-optical sensitivity parameters, namely specific tissue optical index (STOI) and intracranial tissue optical index (ITOI) for effective triaging of patients with suspected traumatic brain injury (TBI) across different age-groups to facilitate timely intervention and curtail the silent epidemic.

RESEARCH DESIGN

Prospective, observational, double-blinded, cross-sectional single-center.

METHODS

A total of 240 subjects suspected with TBI and recommended for head CT scan were enrolled. Findings of CT were compared with the bio-optical sensitivity parameters (STOI+ITOI) generated by the mNIRS system to detect intracranial hemorrhages (ICHs).

STATISTICAL SOFTWARE USED: SPSS (IBM VERSION 21.0) RESULTS

Bio-optical sensitivity parameters (STOI+ITOI) analysis of 1288 scanned lobes showed high specificity of 97% (CI 95-98%), sensitivity of 96% (CI 92-99%), and accuracy of 97% (CI 96-98%) across all ages, maintaining robust performance for detecting subdural, epidural, subarachnoid hemorrhages, and contusions. Also, the reliability in the diagnosis of ICH was evidenced by Youden's index of 0.93 and positive and negative likelihood ratios of 29.13 and 0.04, respectively.

CONCLUSION

The mNIRS-based STOI+ITOI proves to be an effective triage tool for TBI, exhibiting superior diagnostic performance across all age-groups.

Prehospital identification of intracerebral haemorrhage: a scoping review of early clinical features and portable devices

INTRODUCTION

Prehospital identification of intracerebral haemorrhage (ICH) in suspected stroke cases may enable the initiation of appropriate treatments and facilitate better-informed transport decisions. This scoping review aims to examine the literature to identify early clinical features and portable devices for the detection of ICH in the prehospital setting.

METHODS

Three databases were searched via Ovid (MEDLINE, EMBASE and CENTRAL) from inception to August 2022 using prespecified search strategies. One reviewer screened all titles, abstracts and full-text articles for eligibility, while a second reviewer independently screened 20% of the literature during each screening stage. Data extracted were tabulated to summarise the key findings.

RESULTS

A total of 6803 articles were screened for eligibility, of which 22 studies were included for analysis. Among them, 15 studies reported on early clinical features, while 7 considered portable devices. Associations between age, sex and comorbidities with the presence of ICH varied across studies. However, most studies reported that patients with ICH exhibited more severe neurological deficits (n=6) and higher blood pressure levels (n=11) at onset compared with other stroke and non-stroke diagnoses. Four technologies were identified for ICH detection: microwave imaging technology, volumetric impedance phase shift spectroscopy, transcranial ultrasound and electroencephalography. Microwave and ultrasound imaging techniques showed promise in distinguishing ICH from other diagnoses.

CONCLUSION

This scoping review has identified potential clinical features for the identification of ICH in suspected stroke patients. However, the considerable heterogeneity among the included studies precludes meta-analysis of available data. Moreover, we have explored portable devices to enhance ICH identification. While these devices have shown promise in detecting ICH, further technological development is required to distinguish between stroke subtypes (ICH vs ischaemic stroke) and non-stroke diagnoses.

Clinical Utility of Near-Infrared Device in Detecting Traumatic Intracranial Hemorrhage: A Pilot Study Toward Application as an Emergent Diagnostic Modality in a Low-Resource Setting

Limited computed tomography (CT) availability in low- and middle-income countries frequently impedes life-saving neurosurgical decompression for traumatic brain injury. A reliable, accessible, cost-effective solution is necessary to detect and localize bleeds. We report the largest study to date using a near-infrared device (NIRD) to detect traumatic intracranial bleeds. Patients with confirmed or suspected head trauma who received a head CT scan were included. Within 30 min of the initial head CT scan, a blinded examiner scanned each patient's cranium with a NIRD, interrogating bilaterally the frontal, parietal, temporal, and occipital quadrants Sensitivity, specificity, accuracy, and precision were investigated. We recruited 500 consecutive patients; 104 patients had intracranial bleeding. For all patients with CT-proven bleeds, irrespective of size, initial NIRD scans localized the bleed to the appropriate quadrant with a sensitivity of 86% and specificity of 96% compared with CT. For extra-axial bleeds >3.5mL, sensitivity and specificity were 94% and 96%, respectively. For longitudinal serial rescans with the NIRD, sensitivity was 89% (< 4 days from injury: sensitivity: 99%), and specificity was 96%. For all patients who required craniectomy or craniotomy, the device demonstrated 100% sensitivity. NIRD is highly sensitive, specific, and reproducible over time in diagnosing intracranial bleeds. NIRD may inform neurosurgical decision making in settings where CT scanning is unavailable or impractical.

Mapping access to care and identification of barriers for traumatic brain injury in a South African township

RATIONALE

South Africa has a high traumatic injury burden resulting in a significant number of persons suffering from traumatic brain injury (TBI). TBI is a time-sensitive condition requiring a responsive and organized health system to minimize morbidity and mortality. This study outlined the barriers to accessing TBI care in a South African township.

METHODS

This was a multimethod study. A facility survey was carried out on health facilities offering trauma care in Khayelitsha township, Cape Town, South Africa. Perceived barriers to accessing TBI care were explored using qualitative interviews and focus group discussions. The four-delay framework that describes delays in four phases was used: seeking, reaching, receiving, and remaining in care. We purposively recruited individuals with a history of TBI (n = 6) and 15 healthcare professionals working with persons with TBI (seven individuals representing each of the five facilities, the heads of neurosurgery and emergency medical services and eight additional healthcare providers who participated in the focus group discussions). Quantitative data were analysed descriptively while qualitative data were analysed thematically, following inductive and deductive approaches.

FINDINGS

Five healthcare facilities (three community health centres, one district hospital and one tertiary hospital) were surveyed. We conducted 13 individual interviews (six with persons with TBI history, seven with healthcare providers from each of the five facilities, neurosurgery department and emergency medical service heads and two focus group discussions involving eight additional healthcare providers. Participants mentioned that alcohol abuse and high neighbourhood crime could lead to delays in seeking and reaching care. The most significant barriers reported were related to receiving definitive care, mostly due to a lack of diagnostic imaging at community health centres and the district hospital, delays in interfacility transfers due to ambulance delays and human and infrastructural limitations. A barrier to remaining in care was the lack of clear communication between persons with TBI and health facilities regarding follow-up care.

CONCLUSION

Our study revealed that various individual-level, community and health system factors impacted TBI care. Efforts to improve TBI care and reduce injury-related morbidity and mortality must put in place more community-level security measures, institute alcohol regulatory policies, improve access to diagnostics and invest in hospital infrastructures.

Near-infrared spectroscopy for intracranial hemorrhage detection in traumatic brain injury patients: A systematic review

PURPOSE

To synthesize evidence of the use of near-infrared spectroscopy (NIRS) to detect intracranial hemorrhage in traumatic brain injury (TBI) patients.

METHODS

The literature search was conducted in PubMed and Google Scholar (from inception to July 2021).

RESULTS

216 original articles were found, 197 of which were omitted, and the final review contained 19 original articles covering 2291 patients.

CONCLUSION

For patients with TBI, a NIRS test may be useful as a screening tool for intracranial hemorrhage, especially at the prehospital level. Negative results may help rule out intracranial hemorrhage and may remove the need for more head computed tomography (CT) scanning. Prehospital testing may guide the decision of whether the patient should be transferred to a craniotomy-equipped specialized hospital. NIRS can also be useful in situations when CT is not available. For future research, a significant objective is to show whether the effects of NIRS can improve outcomes and lead to meaningful improvements in clinical practice and decision making.

Near Infrared Spectroscopy for High-Temporal Resolution Cerebral Physiome Characterization in TBI: A Narrative Review of Techniques, Applications, and Future Directions

Multimodal monitoring has been gaining traction in the critical care of patients following traumatic brain injury (TBI). Through providing a deeper understanding of the individual patient's comprehensive physiologic state, or "physiome," following injury, these methods hold the promise of improving personalized care and advancing precision medicine. One of the modalities being explored in TBI care is near-infrared spectroscopy (NIRS), given it's non-invasive nature and ability to interrogate microvascular and tissue oxygen metabolism. In this narrative review, we begin by discussing the principles of NIRS technology, including spatially, frequency, and time-resolved variants. Subsequently, the applications of NIRS in various phases of clinical care following TBI are explored. These applications include the pre-hospital, intraoperative, neurocritical care, and outpatient/rehabilitation setting. The utility of NIRS to predict functional outcomes and evaluate dysfunctional cerebrovascular reactivity is also discussed. Finally, future applications and potential advancements in NIRS-based physiologic monitoring of TBI patients are presented, with a description of the potential integration with other omics biomarkers.

Prehospital Detection of Life-Threatening Intracranial Pathology: An Unmet Need for Severe TBI in Austere, Rural, and Remote Areas

Severe traumatic brain injury (TBI) is a leading cause of death and disability worldwide, especially in low- and middle-income countries, and in austere, rural, and remote settings. The purpose of this Perspective is to challenge the notion that accurate and actionable diagnosis of the most severe brain injuries should be limited to physicians and other highly-trained specialists located at hospitals. Further, we aim to demonstrate that the great opportunity to improve severe TBI care is in the prehospital setting. Here, we discuss potential applications of prehospital diagnostics, including ultrasound and near-infrared spectroscopy (NIRS) for detection of life-threatening subdural and epidural hemorrhage, as well as monitoring of cerebral hemodynamics following severe TBI. Ultrasound-based methods for assessment of cerebrovascular hemodynamics, vasospasm, and intracranial pressure have substantial promise, but have been mainly used in hospital settings; substantial development will be required for prehospital optimization. Compared to ultrasound, NIRS is better suited to assess certain aspects of intracranial pathology and has a smaller form factor. Thus, NIRS is potentially closer to becoming a reliable method for non-invasive intracranial assessment and cerebral monitoring in the prehospital setting. While one current continuous wave NIRS-based device has been FDA-approved for detection of subdural and epidural hemorrhage, NIRS methods using frequency domain technology have greater potential to improve diagnosis and monitoring in the prehospital setting. In addition to better technology, advances in large animal models, provider training, and implementation science represent opportunities to accelerate progress in prehospital care for severe TBI in austere, rural, and remote areas.

Diagnostic properties of a portable near-infrared spectroscopy to detect intracranial hematoma in traumatic brain injury patients

Traumatic brain injury (TBI) is a major public health issue worldwide. A portable near-infrared spectroscopy (NIRS) is a non-invasive device to detect intracranial hematoma. The advantages of the NIRS include real time results and non-radiation exposure. However, sensitivity and specificity of the NIRS for intracranial hematoma are varied. This study aimed to evaluate the diagnostic properties of the NIRS in TBI patients to detect intracranial hematoma. This study was a diagnostic and prospective study conducted at the Emergency Department. The inclusion criteria were adult patients (age of 18 years or over) with moderate to high risk of all degrees of traumatic brain injury within 24 h after the injury. The primary endpoint of the study was a description of diagnostic properties of the NIRS compared with the CT brain. There were 47 patients enrolled in the study. Most of patients had Glasgow Coma Scale of 15 (44 patients; 93.62 %). Of those, 11 patients (23.40 %) had intracranial hematoma: subdural hematoma (n = 9), epidural hematoma (n = 1), intracerebral hematoma (n = 1), and subarachnoid hemorrhage (n = 3). One patient had subdural hematoma, epidural hematoma, intracerebral hematoma and subarachnoid hemorrhage. There were 31 patients had abnormal findings by the NIRS but only 11 patients had bleeding detected by the CT brain. There were 16 patients had negative results on both the NIRS and the CT brain. The sensitivity and specificity of the NIRS compared with the CT brain was 100 % and 44.4 %, respectively. The area under the ROC curve of the NIRS was 0.722. The median time to complete the NIRS examination was 3 min. In conclusion, the NIRS has high sensitivity and negative predictive value for intracranial hematoma detection in mild TBI patients with extra-axial hematomas.

Quickly Evaluating an Emerging Medical Technology Using Feedback From the Field: A Case Study of the BrainScope One and Infrascanner 2000 User Evaluation

Introduction

Gathering end-user feedback about candidate technologies in the operational environment prior to fielding helps to ensure that far-forward medical teams receive the most suitable technology. It is therefore a crucial step in the defense medical acquisition process. The current article reviews the methodology and provides an illustrative example of how end-user feedback was collected to evaluate the current suitability and future promise of two FDA-approved devices, the BrainScope One and Infrascanner 2000, that could potentially aid in the field evaluation of head injuries by far-forward medical teams.

Materials and Method

The BrainScope One and Infrascanner 2000 end-user evaluation is used as an example to illustrate how to collect end-user feedback from the field in order to rapidly assess the candidate technology. In this evaluation of whether and how to implement FDA-approved technology candidates for head injury assessment by far-forward medical teams, end-user feedback was collected from 158 medical personnel at 8 bases in Afghanistan, Iraq, and Kuwait using focus groups and interviews.

Results

The end users reported consistent concerns about the operational efficacy and suitability of the current versions of the devices as well as the areas where the devices showed promise for the Department of Defense (DoD). End-user feedback is shown in detail to demonstrate the depth and richness of feedback that can be gathered using this methodology.

Conclusion

Overall, the BrainScope One and Infrascanner 2000 end-user evaluation shows the necessity and value of gathering end-user field efficacy and suitability feedback during the medical acquisition process. Limitations and best practices for this approach are discussed.

Preparing the Intensive Care Unit for Disaster

Critical care teams can face a dramatic surge in demand for ICU beds and organ support during a disaster. Through effective preparedness, teams can enable a more effective response and hasten recovery back to normal operations. Disaster preparedness needs to balance an all-hazards approach with focused hazard-specific preparation guided by a critical care-specific hazard-vulnerability analysis. Broad stakeholder input from within and outside the critical care team is necessary to avoid gaps in planning. Evaluation of critical care disaster plans require frequent exercises, with a mechanism in place to ensure lessons learned effectively prompt improvements in the plan.

Chinese Military Evaluation of a Portable Near-Infrared Detector of Traumatic Intracranial Hematomas

Introduction

Secondary brain injury is the main cause of mortality from traumatic brain injury (TBI). One hallmark of TBI is intracranial hemorrhage, which occurs in 40-50% of severe TBI cases. Early identification of intracranial hematomas in TBI patients allows early surgical evacuation and can reduce the case fatality rate of TBI. As pre-hospital care is the weakest part of Chinese emergency care, there is an urgent need for a capability to detect brain hematomas early. In China, in addition to preventing injuries and diseases in military staff and in enhancing the military armed forces during war, military medicine participates in actions such as emergency public health crises, natural disasters, emerging conflicts, and anti-terrorist campaigns during peacetime. The purpose of this observational study is to evaluate in the Chinese military general hospital the performance of a near-infrared (NIR)-based portable device, developed for US Military, in the detection of traumatic intracranial hematomas. The endpoint of the study was a description of the test characteristics (sensitivity, specificity, and positive and negative predictive values [NPV]) of the portable NIR-based device in identification of hematomas within its detection limits (volume >3.5 mL and depth <2.5 cm) compared with computed tomography (CT) scans as the gold standard.

Materials and Methods

The Infrascanner Model 2000 NIR device (InfraScan, Inc., Philadelphia, PA, USA) was used for hematoma detection in patients sustaining TBI. Data were collected in the People's Liberation Army General Hospital in Beijing using the NIR device at the time of CT scans, which were performed to evaluate suspected TBI. One hundred and twenty seven patients were screened, and 102 patients were included in the per protocol population. Of the 102 patients, 24 were determined by CT scan to have intracranial hemorrhage. The CT scans were read by an independent neuroradiologist who was blinded to the NIR measurements.

Results

The NIR device demonstrated sensitivity of 100% (95% confidence intervals [CI] 82.8-100%) and specificity of 93.6% (95%CI 85-97.6%) in detecting intracranial hematomas larger than 3.5 mL in volume and that were less than 2.5 cm from the surface of the brain. Blood contained within scalp hematomas was found to be a major cause of false-positive results with this technology.

Conclusion

The study showed that the Infrascanner is a suitable portable device in Chinese population for detecting preoperative intracranial hematomas in remote locations, emergency rooms, and intensive care units. It could aid military medics, physicians, and hospital staff, permitting better triage decisions, earlier treatment, and reducing secondary brain injury caused by acute and delayed hematomas.

Phantom-based evaluation of near-infrared intracranial hematoma detector performance

Near-infrared spectroscopy (NIRS) is emerging as a rapid, low-cost approach for point-of-care triage of hematomas resulting from traumatic brain injury. However, there remains a lack of standardized test methods for benchtop performance assessment of these devices and incomplete understanding of relevant light-tissue interactions. We propose a phantom-based test method for systems operating near the 800-nm oxy-/deoxy-hemoglobin isosbestic point and implement it to evaluate a clinical system. Semi-idealized phantom geometries are designed to represent epidural/subdural, subarachnoid, and intracerebral hemorrhages. Measurements of these phantoms are made with a commercial NIRS-based hematoma detector to quantify the effect of hematoma type, depth, and size, as well as measurement repeatability and detector positioning relative to the hematoma. Results indicated high sensitivity to epidural/subdural and subarachnoid hematomas. Intracerebral hematomas are detectable to a maximum depth of ∼2.5  cm, depending on thickness and diameter. The maximum lateral detection area for the single-emitter/single-collector device studied here appears elliptical and decreases strongly with inclusion depth. Overall, this study provides unique insights into hematoma detector function and indicates the utility of modular polymer tissue phantoms in performance tests for emerging NIRS-based cerebral diagnostic technology.

Early diagnosis of traumatic intracranial hematomas

Timing of the intervention for intracranial hematomas is critical for its success, specifically since expansion of the hemorrhage can result in debilitating and sometimes fatal outcomes. Led by Britton Chance, we and an extended team from University of Pennsylvania, Baylor and Drexel universities developed a handheld brain hematoma detector for early triage and diagnosis of head trauma victims. After obtaining de novo Food and Drug Administration clearance, over 200 systems are deployed in all Marine battalion aid stations around the world. Infrascanner, a handheld brain hematoma detection system, is based on the differential near-infrared light absorption of the injured versus the noninjured part of brain. About 12 independent studies have been conducted in the USA, Canada, Spain, Italy, the Netherlands, Germany, Russia, Poland, Afghanistan, India, China, and Turkey. Here, we outline the background and design of the device as well as clinical studies with a total of 1293 patients and 203 hematomas. Infrascanner demonstrates high sensitivity (adults: 92.5% and children: 93%) and specificity (adults: 82.9% and children: 86.5%) in detecting intracranial hematomas >3.5  mL in volume and <2.5  cm from the surface of the brain. Infrascanner is a clinically effective screening solution for head trauma patients in prehospital settings where timely triage is critical.

Current and future functional imaging techniques for post-traumatic stress disorder

Posttraumatic stress disorder (PTSD) is a trauma and stressor related psychiatric disorder associated with structural, metabolic, and molecular alternations in several brain regions including diverse cortical areas, neuroendocrine regions, the striatum, dopaminergic, adrenergic and serotonergic pathways, and the limbic system. We are in critical need of novel therapeutics and biomarkers for PTSD and a deep understanding of cutting edge imaging and spectroscopy methods is necessary for the development of promising new approaches to better diagnose and treat the disorder. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criterion, all forms of traumatic stress-induced disorder are considered acute stress disorder for the first month following the stressor. Only after symptoms do not remit for one month can the disorder be deemed PTSD. It would be particularly useful to differentiate between acute stress disorder and PTSD during the one month waiting period so that more intensive treatments can be applied early on to patients with a high likelihood of developing PTSD. This would potentially enhance treatment outcomes and/or prevent the development of PTSD. Comprehension of the qualities and limitations of currently applied methods as well as the novel emerging techniques provide invaluable knowledge for fast paced development. Conventional methods of studying PTSD have proven to be insufficient for diagnosis, measurement of treatment efficacy, and monitoring disease progression. As the field currently stands, there is no diagnostic biomarker available for any psychiatric disease, PTSD included. Currently, emerging and available technologies are not utilized to their full capacity and in appropriate experimental designs for the most fruitful possible studies in this area. Therefore, there is an apparent need for improved methods in PTSD research. This review demonstrates the current state of the literature in PTSD, including molecular, cellular, and behavioral indicators, possible biomarkers and clinical and pre-clinical imaging techniques relevant to PTSD, and through this, elucidate the void of current practical imaging and spectroscopy methods that provide true biomarkers for the disorder and the significance of devising new techniques for future investigations. We are unlikely to develop a single biomarker for any psychiatric disorder however. As psychiatric disorders are incomparably complex compared to other medical diagnoses, its most likely that transcriptomic, metabolomic and structural and connectomic imaging data will have to be analyzed in concert in order to produce a dependable non-behavioral marker of PTSD. This can explain the necessity of bridging conventional approaches to novel technologies in order to create a framework for further discoveries in the treatment of PTSD.

Conventional methods of studying posttraumatic stress disorder (PTSD) have proven to be insufficient for diagnosis. We have reviewed clinical and preclinical imaging techniques as well as molecular, cellular, and behavioral indicators for PTSD.

Italian guidelines on the assessment and management of pediatric head injury in the emergency department

OBJECTIVE

We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury.

METHODS

These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text.

CONCLUSIONS

Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.

Microwave technology for detecting traumatic intracranial bleedings: tests on phantom of subdural hematoma and numerical simulations

Traumatic brain injury is the leading cause of death and severe disability for young people and a major public health problem for elderly. Many patients with intracranial bleeding are treated too late, because they initially show no symptoms of severe injury and are not transported to a trauma center. There is a need for a method to detect intracranial bleedings in the prehospital setting. In this study, we investigate whether broadband microwave technology (MWT) in conjunction with a diagnostic algorithm can detect subdural hematoma (SDH). A human cranium phantom and numerical simulations of SDH are used. Four phantoms with SDH 0, 40, 70 and 110 mL are measured with a MWT instrument. The simulated dataset consists of 1500 observations. Classification accuracy is assessed using fivefold cross-validation, and a validation dataset never used for training. The total accuracy is 100 and 82-96 % for phantom measurements and simulated data, respectively. Sensitivity and specificity for bleeding detection were 100 and 96 %, respectively, for the simulated data. SDH of different sizes is differentiated. The classifier requires training dataset size in order of 150 observations per class to achieve high accuracy. We conclude that the results indicate that MWT can detect and estimate the size of SDH. This is promising for developing MWT to be used for prehospital diagnosis of intracranial bleedings.

Evaluation of light detector surface area for functional Near Infrared Spectroscopy

Functional Near Infrared Spectroscopy (fNIRS) is an emerging neuroimaging technique that utilizes near infrared light to detect cortical concentration changes of oxy-hemoglobin and deoxy-hemoglobin non-invasively. Using light sources and detectors over the scalp, multi-wavelength light intensities are recorded as time series and converted to concentration changes of hemoglobin via modified Beer-Lambert law. Here, we describe a potential source for systematic error in the calculation of hemoglobin changes and light intensity measurements. Previous system characterization and analysis studies looked into various fNIRS parameters such as type of light source, number and selection of wavelengths, distance between light source and detector. In this study, we have analyzed the contribution of light detector surface area to the overall outcome. Results from Monte Carlo based digital phantoms indicated that selection of detector area is a critical system parameter in minimizing the error in concentration calculations. The findings here can guide the design of future fNIRS sensors.

Intracranial Hematoma Detection by Near Infrared Spectroscopy in a Helicopter Emergency Medical Service: Practical Experience

In (helicopter) emergency medical services, (H)EMS, the prehospital detection of intracranial hematomas should improve patient care and the triage to specialized neurosurgical hospitals. Recently, noninvasive detection of intracranial hematomas became possible by applying transcranial near infrared spectroscopy (NIRS). Herein, second-generation devices are currently available, for example, the Infrascanner 2000 (Infrascan), that appear suited also for prehospital (H)EMS applications. Since (H)EMS operations are time-critical, we studied the Infrascanner 2000 as a “first-time-right” monitor in healthy volunteers (n = 17, hospital employees, no neurologic history). Further, we studied the implementation of the Infrascanner 2000 in a European HEMS organization (Lifeliner 1, Amsterdam, The Netherlands). The principal results of our study were as follows: The screening for intracranial hematomas in healthy volunteers with first-time-right intention resulted in a marked rate of virtual hematomas (false positive results, i.e., 12/17), rendering more time consuming repeat measurements advisable. The results of the implementation of the Infrascanner in HEMS suggest that NIRS-based intracranial hematoma detection is feasible in the HEMS setting. However, some drawbacks exist and their possible solutions are discussed. Future studies will have to demonstrate how NIRS-based intracranial hematoma detection will improve prehospital decision making in (H)EMS and ultimately patient outcome.

Near-infrared spectroscopy (NIRS) to detect traumatic intracranial haematoma: A systematic review and meta-analysis

OBJECTIVES AND METHODS

Head injury is the most common trauma presentation to UK emergency departments, with around 1.2 million patients each year. The key management principal for this time critical illness remains early surgical intervention. With the development of handheld near-infrared spectroscopy (NIRS) devices, there is now the possibility of triaging and diagnosing these patients immediately, where computed tomography (CT) scanner is unavailable. NIRS has two related but distinct potential uses within clinical medicine. Firstly, as a triage tool both in hospital and prehospital settings by doctors, nurses or paramedics as determined by its negative predictive value (NPV). Secondly, as a diagnostic aid as determined by its positive predictive value (PPV). The aim of this systematic review and meta-analysis is therefore to interrogate the current literature on NIRS in detecting intracranial haematomas.

RESULTS

NIRS technology has a cross-study sensitivity of 78%, specificity of 90%, PPV of 77%, and a NPV of 90%, which does not meet current standards as a diagnostic/triage tool in the populations studied. Additionally, its use is limited to those without extracranial injuries and may also be complicated by long scan times.

CONCLUSION

Larger and more heterogeneous studies are required for specifically evaluating NIRS performance in detecting intracranial lesions requiring emergency evacuation.

Near-Infrared Spectroscopy: A Promising Prehospital Tool for Management of Traumatic Brain Injury

Introduction

Early identification of traumatic brain injury (TBI) is essential. Near-infrared spectroscopy (NIRS) can be used in prehospital settings for non-invasive monitoring and the diagnosis of patients who may require surgical intervention.

Methods

The handheld NIRS Infrascanner (InfraScan Inc.; Philadelphia, Pennsylvania USA) uses eight symmetrical scan points to detect intracranial bleeding. A scanner was tested in a physician-staffed helicopter Emergency Medical Service (HEMS). The results were compared with those obtained using in-hospital computed tomography (CT) scans. Scan time, ease-of-use, and change in treatment were scored.

Results

A total of 25 patients were included. Complete scans were performed in 60% of patients. In 15 patients, the scan was abnormal, and in one patient, the scan resulted in a treatment change. Compared with the results of CT scanning, the Infrascanner obtained a sensitivity of 93.3% and a specificity of 78.6%. Most patients had severe TBI with indication for transport to a trauma center prior to scanning. In one patient, the scan resulted in a treatment change. Evaluation of patients with less severe TBI is needed to support the usefulness of the Infrascanner as a prehospital triage tool.

Conclusion

Promising results were obtained using the InfraScan NIRS device in prehospital screening for intracranial hematomas in TBI patients. High sensitivity and good specificity were found. Further research is necessary to determine the beneficial effects of enhanced prehospital screening on triage, survival, and quality of life in TBI patients.

PetersJ, Van WageningenB, HoogerwerfN, TanE. Near-infrared spectroscopy: a promising prehospital tool for management of traumatic brain injury. Prehosp Disaster Med. 2017;32(4):414–418.

Clinical Evaluation of a Microwave-Based Device for Detection of Traumatic Intracranial Hemorrhage

Traumatic brain injury (TBI) is the leading cause of death and disability among young persons. A key to improve outcome for patients with TBI is to reduce the time from injury to definitive care by achieving high triage accuracy. Microwave technology (MWT) allows for a portable device to be used in the pre-hospital setting for detection of intracranial hematomas at the scene of injury, thereby enhancing early triage and allowing for more adequate early care. MWT has previously been evaluated for medical applications including the ability to differentiate between hemorrhagic and ischemic stroke. The purpose of this study was to test whether MWT in conjunction with a diagnostic mathematical algorithm could be used as a medical screening tool to differentiate patients with traumatic intracranial hematomas, chronic subdural hematomas (cSDH), from a healthy control (HC) group. Twenty patients with cSDH and 20 HC were measured with a MWT device. The accuracy of the diagnostic algorithm was assessed using a leave-one-out analysis. At 100% sensitivity, the specificity was 75%—i.e., all hematomas were detected at the cost of 25% false positives (patients who would be overtriaged). Considering the need for methods to identify patients with intracranial hematomas in the pre-hospital setting, MWT shows promise as a tool to improve triage accuracy. Further studies are under way to evaluate MWT in patients with other intracranial hemorrhages.

Portable near-infrared rapid detection of intracranial hemorrhage in Chinese population

BACKGROUND

Secondary brain injury is the main cause of mortality from traumatic brain injury (TBI). One hallmark of TBI is intracranial hemorrhage, which occurs in 40-50% of severe TBI cases. Early identification of intracranial hematomas in TBI patients allows early surgical evacuation, and can reduce the case-fatality rate of TBI. Since pre-hospital care is the weakest part of Chinese emergency care, there is an urgent need for a capability to detect brain hematomas early. The purpose of this observational study was to evaluate the performance of a near infrared (NIR) based, device to screen for traumatic intracranial hematomas in Chinese population.

METHODS

Data was collected using the NIR device at the time of a computed tomography (CT) or magnetic resonance imaging (MRI) scan was performed to evaluate a suspected TBI. 85 patients were included in the per protocol population. Of the 85 patients, 45 were determined by CT scan to have intracranial hemorrhage. The CT and MRI scans were read by an independent neuroradiologist who was blinded to the NIR measurements.

RESULTS

The NIR device demonstrated sensitivity of 95.6% (95% confidence intervals [CI] 83.6-99.2%) and specificity of 92.5% (CI 78.5-98%) in detecting intracranial hematomas larger than 3.5ml in volume, and that were less than 2.5cm from the surface of the brain.

CONCLUSION

These results confirm in Chinese population the results of previous studies that demonstrated a NIR based device can reliably screen for intracranial hematomas that are likely to be of clinical importance.

[Near-infrared spectroscopy for the detection of traumatic intracranial hemorrhage: Feasibility study in a German army field hospital in Afghanistan]

Traumatic brain injury (TBI) is one of the most common causes of death in ordinary accidents, natural disasters, or warfare. The gold standard for diagnosis of TBI is the CT scan; a delay of diagnostics or medical care is the strongest independent predictor of mortality of TBI patients--particularly in the case of a surgically treatable intracranial hematoma. The proper classification of these patients is of major importance in situations where a CT is not accessible. A portable screening device that uses near-infrared spectroscopy (NIRS) technology allows a preliminary estimate of an intracranial hematoma. This study assessing practicability shows that the use of the device in a military medical rescue center (Kunduz, Afghanistan) is easy to learn and can be repeatedly used even under emergency room conditions. The technique can be applied in penetrating and blunt TBIs in the absence of an immediately available CT scan in rural areas, preclinically, under mass casualty conditions (e.g., in disaster situations) as well as in humanitarian crises or war zones. Nevertheless, further studies to assess the validity of this device are necessary.

Application of optical methods in the monitoring of traumatic brain injury: A review

We present an overview of the wide range of potential applications of optical methods for monitoring traumatic brain injury. The MEDLINE database was electronically searched with the following search terms: "traumatic brain injury," "head injury," or "head trauma," and "optical methods," "NIRS," "near-infrared spectroscopy," "cerebral oxygenation," or "cerebral oximetry." Original reports concerning human subjects published from January 1980 to June 2015 in English were analyzed. Fifty-four studies met our inclusion criteria. Optical methods have been tested for detection of intracranial lesions, monitoring brain oxygenation, assessment of brain perfusion, and evaluation of cerebral autoregulation or intracellular metabolic processes in the brain. Some studies have also examined the applicability of optical methods during the recovery phase of traumatic brain injury . The limitations of currently available optical methods and promising directions of future development are described in this review. Considering the outstanding technical challenges, the limited number of patients studied, and the mixed results and opinions gathered from other reviews on this subject, we believe that optical methods must remain primarily research tools for the present. More studies are needed to gain confidence in the use of these techniques for neuromonitoring of traumatic brain injury patients.

Ambulatory diffuse optical tomography and multimodality physiological monitoring system for muscle and exercise applications

Ambulatory diffuse optical tomography (aDOT) is based on near-infrared spectroscopy (NIRS) and enables three-dimensional imaging of regional hemodynamics and oxygen consumption during a person’s normal activities. Although NIRS has been previously used for muscle assessment, it has been notably limited in terms of the number of channels measured, the extent to which subjects can be ambulatory, and/or the ability to simultaneously acquire synchronized auxiliary data such as electromyography (EMG) or electrocardiography (ECG). We describe the development of a prototype aDOT system, called NINscan-M, capable of ambulatory tomographic imaging as well as simultaneous auxiliary multimodal physiological monitoring. Powered by four AA size batteries and weighing 577 g, the NINscan-M prototype can synchronously record 64-channel NIRS imaging data, eight channels of EMG, ECG, or other analog signals, plus force, acceleration, rotation, and temperature for 24+ h at up to 250 Hz. We describe the system’s design, characterization, and performance characteristics. We also describe examples of isometric, cycle ergometer, and free-running ambulatory exercise to demonstrate tomographic imaging at 25 Hz. NINscan-M represents a multiuse tool for muscle physiology studies as well as clinical muscle assessment.

Clinical application of near-infrared spectroscopy in patients with traumatic brain injury: a review of the progress of the field

Near-infrared spectroscopy (NIRS) is a technique by which the interaction between light in the near-infrared spectrum and matter can be quantitatively measured to provide information about the particular chromophore. Study into the clinical application of NIRS for traumatic brain injury (TBI) began in the 1990s with early reports of the ability to detect intracranial hematomas using NIRS. We highlight the advances in clinical applications of NIRS over the past two decades as they relate to TBI. We discuss recent studies evaluating NIRS techniques for intracranial hematoma detection, followed by the clinical application of NIRS in intracranial pressure and brain oxygenation measurement, and conclude with a summary of potential future uses of NIRS in TBI patient management.

Infrascanner in the diagnosis of intracranial lesions in children with traumatic brain injuries

BACKGROUND

The number of traumatic injuries among children is increasing. However, so-called mild TBI might result in unfavourable outcomes. Early diagnosis of intracranial haematomas prior to development of serious complications may be a decisive factor for a favourable outcome. InfraScan company developed and brought to the market the Infrascanner model 1000, which is a portable detector of blood collections that operates in the near infrared (NIR) band.

OBJECTIVE

To estimate the efficiency of the Infrascanner model 1000 for detection of intracranial haematomas among children with mild TBI.

MATERIALS AND METHODS

Ninety-five patients with mild TBI were examined. An indication for cerebral CT after mild TBI was the presence of risk factors of intracranial lesions. The Infrascanner was used by a neurosurgeon during primary examination. CT was performed in 43 patients (45%), while 52 patients (55%) with a low risk of intracranial lesions were under observation.

RESULTS

The results of examination of patients using CT and infrared scanning coincided in 39 cases and intracranial haematomas were detected in eight patients. False-positive results were obtained in three cases. The sensitivity of the procedure used in this group of patients with a medium and high risk of development of intracranial haemorrhages was 1.00 (0.66; 1.00). The specificity was 0.91 (0.81; 1.00)--the proportions and a 95% CI. The false-positive risk is 0.27 (0.00; 0.58). During infrared scanning in patients with low risk of intracranial lesions, false-positive results were obtained in four cases and false-negative results were absent.

CONCLUSION

Infra-scanning might be viewed as a screening technique for intracranial haemorrhages in ambulances and outpatient trauma centres in order to decide on hospitalization, CT scanning and referral to a neurosurgeon. Infra-scanning combined with evaluation of risk factors of intracranial damage might reduce the number of unnecessary radiological examinations.

Identification of hematomas in mild traumatic brain injury using an index of quantitative brain electrical activity

Rapid identification of traumatic intracranial hematomas following closed head injury represents a significant health care need because of the potentially life-threatening risk they present. This study demonstrates the clinical utility of an index of brain electrical activity used to identify intracranial hematomas in traumatic brain injury (TBI) presenting to the emergency department (ED). Brain electrical activity was recorded from a limited montage located on the forehead of 394 closed head injured patients who were referred for CT scans as part of their standard ED assessment. A total of 116 of these patients were found to be CT positive (CT+), of which 46 patients with traumatic intracranial hematomas (CT+) were identified for study. A total of 278 patients were found to be CT negative (CT-) and were used as controls. CT scans were subjected to quantitative measurements of volume of blood and distance of bleed from recording electrodes by blinded independent experts, implementing a validated method for hematoma measurement. Using an algorithm based on brain electrical activity developed on a large independent cohort of TBI patients and controls (TBI-Index), patients were classified as either positive or negative for structural brain injury. Sensitivity to hematomas was found to be 95.7% (95% CI = 85.2, 99.5), specificity was 43.9% (95% CI = 38.0, 49.9). There was no significant relationship between the TBI-Index and distance of the bleed from recording sites (F = 0.044, p = 0.833), or volume of blood measured F = 0.179, p = 0.674). Results of this study are a validation and extension of previously published retrospective findings in an independent population, and provide evidence that a TBI-Index for structural brain injury is a highly sensitive measure for the detection of potentially life-threatening traumatic intracranial hematomas, and could contribute to the rapid, quantitative evaluation and treatment of such patients.

The use of handheld near-infrared device (Infrascanner)for detecting intracranial haemorrhages in children with minor head injury

OBJECTIVE

A handheld device using near-infrared technology(Infrascanner) has shown good accuracy for detection of traumatic intracranial haemorrhages in adults. This study aims to determine the feasibility of use of Infrascanner in children with minor head injury (MHI) in the Emergency Department(ED). Secondary aim was to assess its potential usefulness to reduce CT scan rate.

METHODS

Prospective pilot study conducted in two paediatric EDs, including children at high or intermediate risk for clinically important traumatic brain injury (ciTBI) according to the adapted PECARN rule in use. Completion of Infrascanner measurements and time to completion were recorded. Decision on CT scan and CT scan reporting were performed independently and blinded to Infrascanner results.

RESULTS

Completion of the Infrascanner measurement was successfully achieved in 103 (94 %) of 110 patients enrolled,after a mean of 4.4±2.9 min. A CT scan was performed in 18(17.5 %) children. Only one had an intracranial haemorrhage that was correctly identified by the Infrascanner. The exploratory analysis showed a specificity of 93 % (95 % CI, 86.5–96.6) and a negative predictive value of 100 % (95 % CI,81.6–100) for ciTBI. The use of Infrascanner would have led to avoid ten CT scan, reducing the CT scan rate by 58.8 %.

CONCLUSIONS

Infrascanner seems an easy-to-use tool for children presenting to the ED following a MHI, given the high completion rate and short time to completion. Our preliminary results suggest that Infrascanner is worthy of further investigation as a potential tool to decrease the CT scan rate in children with MHI.

Neurotrauma - a multidisciplinary disease

Traumatic brain injury is one of the most important diseases of our time, both in terms of morbidity, mortality and economic loss. Public health policy is key to reducing its incidence. Integrated multidisciplinary clinical care is vital to minimise its morbidity and mortality.

Use of brain electrical activity for the identification of hematomas in mild traumatic brain injury

This study investigates the potential clinical utility in the emergency department (ED) of an index of brain electrical activity to identify intracranial hematomas. The relationship between this index and depth, size, and type of hematoma was explored. Ten minutes of brain electrical activity was recorded from a limited montage in 38 adult patients with traumatic hematomas (CT scan positive) and 38 mild head injured controls (CT scan negative) in the ED. The volume of blood and distance from recording electrodes were measured by blinded independent experts. Brain electrical activity data were submitted to a classification algorithm independently developed traumatic brain injury (TBI) index to identify the probability of a CT+traumatic event. There was no significant relationship between the TBI-Index and type of hematoma, or distance of the bleed from recording sites. A significant correlation was found between TBI-Index and blood volume. The sensitivity to hematomas was 100%, positive predictive value was 74.5%, and positive likelihood ratio was 2.92. The TBI-Index, derived from brain electrical activity, demonstrates high accuracy for identification of traumatic hematomas. Further, this was not influenced by distance of the bleed from the recording electrodes, blood volume, or type of hematoma. Distance and volume limitations noted with other methods, (such as that based on near-infrared spectroscopy) were not found, thus suggesting the TBI-Index to be a potentially important adjunct to acute assessment of head injury. Because of the life-threatening risk of undetected hematomas (false negatives), specificity was permitted to be lower, 66%, in exchange for extremely high sensitivity.

The use of handheld near-infrared device (Infrascanner) for detecting intracranial haemorrhages in children with minor head injury

OBJECTIVE

A handheld device using near-infrared technology (Infrascanner) has shown good accuracy for detection of traumatic intracranial haemorrhages in adults. This study aims to determine the feasibility of use of Infrascanner in children with minor head injury (MHI) in the Emergency Department (ED). Secondary aim was to assess its potential usefulness to reduce CT scan rate.

METHODS

Prospective pilot study conducted in two paediatric EDs, including children at high or intermediate risk for clinically important traumatic brain injury (ciTBI) according to the adapted PECARN rule in use. Completion of Infrascanner measurements and time to completion were recorded. Decision on CT scan and CT scan reporting were performed independently and blinded to Infrascanner results.

RESULTS

Completion of the Infrascanner measurement was successfully achieved in 103 (94 %) of 110 patients enrolled, after a mean of 4.4 ± 2.9 min. A CT scan was performed in 18 (17.5 %) children. Only one had an intracranial haemorrhage that was correctly identified by the Infrascanner. The exploratory analysis showed a specificity of 93 % (95 % CI, 86.5-96.6) and a negative predictive value of 100 % (95 % CI, 81.6-100) for ciTBI. The use of Infrascanner would have led to avoid ten CT scan, reducing the CT scan rate by 58.8 %.

CONCLUSIONS

Infrascanner seems an easy-to-use tool for children presenting to the ED following a MHI, given the high completion rate and short time to completion. Our preliminary results suggest that Infrascanner is worthy of further investigation as a potential tool to decrease the CT scan rate in children with MHI.

What is New and Innovative in Emergency Neurosurgery? Emerging Diagnostic Technologies Provide Better Care and Influence Outcome: A Specialist Review

The development of emergency medical services and especially neurosurgical emergencies during recent decades has necessitated the development of novel tools. Although the gadgets that the neurosurgeon uses today in emergencies give him important help in diagnosis and treatment, we still need new technology, which has rapidly developed. This review presents the latest diagnostic tools, which offer precious help in everyday emergency neurosurgery practice. New ultrasound devices make the diagnosis of haematomas easier. In stroke, the introduction of noninvasive new gadgets aims to provide better treatment to the patient. Finally, the entire development of computed tomography and progress in radiology have resulted in innovative CT scans and angiographic devices that advance the diagnosis, treatment, and outcome of the patent. The pressure on physicians to be quick and effective and to avoid any misjudgement of the patient has been transferred to the technology, with the emphasis on developing new systems that will provide our patients with a better outcome and quality of life.

The sooner patients begin neurorehabilitation, the better their functional outcome

PRIMARY OBJECTIVE

To determine whether early neurorehabilitation improves a patient's functional recovery.

RESEARCH DESIGN

A retrospective study was carried out on patients with severe traumatic brain injury (TBI) who underwent a minimum of 4 months of integral and multidisciplinary neurorehabilitation.

METHODS AND PROCEDURES

Fifty-eight patients with severe TBI were assessed at admission and at discharge using the FIM + FAM scale. Two groups were formed based on time elapsed from brain injury to onset of rehabilitation. The early treatment group (ET) included patients who began rehabilitation within the first 9 months post-trauma; the late treatment group (LT) began after the 9-month cut-off date. Intra- and between-group analysis of FIM + FAM scores were carried out at admission and discharge. Multiple linear regression was used to determine the best predictors for functional rehabilitation.

MAIN OUTCOMES AND RESULTS

After neurorehabilitation, all subjects showed significant improvement in cognitive, motor, communication and psychosocial functioning. Moreover, the ET group showed better global functional outcome at discharge than patients who began later treatment. The best predictors for functional neurorehabilitation were months since injury, age, GCS score and months of treatment.

CONCLUSIONS

It is concluded that the sooner patients begin neurorehabilitation, the better their functional outcome.

Updates in the management of intracranial pressure in traumatic brain injury

PURPOSE OF REVIEW

Traumatic brain injury remains a common and often debilitating event across the world, producing significant burdens upon health and social care. Effective neurocritical care coupled with timely and appropriate neurosurgical intervention can produce significant improvements in patient outcome. There remains controversy about how best to manage intracranial pressure on the ICU; we review the recent literature addressing a number of key variables.

RECENT FINDINGS

Treatment of elevations in intracranial pressure can begin at the roadside and end on the ICU unit via a number of routes. Prehospital physician-led care may produce significant benefits in outcome which extend beyond airway management. Routine use of cooling worsens the respiratory outcomes without large improvement in neurological endpoints. The use of brain tissue oxygen monitoring is extending and increasingly used to guide management. Decompressive craniectomy in refractory intracranial hypertension has been associated with poor functional outcomes; a large multicentre trial is currently comparing it against barbiturate coma.

SUMMARY

The role of the neurointensivist in outcome for patients who suffer severe traumatic brain injury is key. Targeted therapies are allowing early detection and manipulation of brain ischaemia leading to more individualized treatment.

A hematoma detector-a practical application of instrumental motion as signal in near infra-red imaging

In this paper we discuss results based on using instrumental motion as a signal rather than treating it as noise in Near Infra-Red (NIR) imaging. As a practical application to demonstrate this approach we show the design of a novel NIR hematoma detection device. The proposed device is based on a simplified single source configuration with a dual separation detector array and uses motion as a signal for detecting changes in blood volume in the dural regions of the head. The rapid triage of hematomas in the emergency room will lead to improved use of more sophisticated/expensive imaging facilities such as CT/MRI units. We present simulation results demonstrating the viability of such a device and initial phantom results from a proof of principle device. The results demonstrate excellent localization of inclusions as well as good quantitative comparisons.