The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment

Efficacy of the Canadian CT Head Rule in Patients Presenting to the Emergency Department with Minor Head Injury

Introduction

Approximately, one in three computed tomography (CT) scans performed for head injury may be avoidable. We evaluate the efficacy of the Canadian CT head rule (CCHR) on head CT imaging in minor head injury (MHI) and its association of Glasgow Coma Scale (GCS) and structural abnormality.

Materials and methods

We conducted a prospective cross-sectional study from May 2018 to October 2019 in the Department of Emergency Medicine, Pushpagiri Institute of Medical Sciences and Research Centre, Thiruvalla, Kerala. The CCHR is applied to patients with MHIs (GCS 13-15) after initial stabilization and it is ascertained, if they require a non-contrast CT head and imaging is done. For those who do not require CT head as per the CCHR are excluded from this study. After imaging the patients who have a positive finding on CT head are admitted and followed up if they underwent any neurosurgical intervention, those with no findings in CT head are discharged from the hospital. A total of 203 patients were included during study period.

Results

A total of 203 patients were included in study with mean age of 49.5 years. Approximately, 70% (142) were male. Sensitivity of CCHR for predicting positive CT finding in the present study sample was 68% and specificity was 42.5%.

Conclusion

Canadian CT head rule is a useful tool in the Emergency Department for predicting the requirement of CT in patients with MHI. Canadian CT head rule can reduce the number of CT scans ordered following MHI in ED, thus improving the healthcare costs.

How to cite this article

Reddy A, Poonthottathil F, Jonnakuti R, Thomas R. Efficacy of the Canadian CT Head Rule in Patients Presenting to the Emergency Department with Minor Head Injury. Indian J Crit Care Med 2024;28(2):148-151.

Assessment of Midline Shift in Postdecompressive Craniectomy Patients in Neurocritical Care: Comparison between Transcranial Ultrasonography and Computerized Tomography

Background

Monitoring and evaluation of intracranial structures remain a fundamental element in the neurointensive care unit. Most used technique to monitor progression is the use of computed tomography (CT) in intracranial hemorrhage (ICH) or stroke. Rapid assessment of brain pathology can be made using CT to analyze the midline shift (MLS), hematoma expansion, and ventricular size, but transferring a patient who is intubated is time and resource-consuming task. Ultrasonography is a noninvasive technique, portable, and has the possibility of fast interpretation.

Aims and Objectives

To measure the brain MLS in decompressive craniectomy patients using transcranial ultrasonography (TCS) and compare the correlation of these results with CT scan measurements of MLS in the same patient.

Materials and Methods

Patients who have undergone decompressive craniectomy due to various reasons like ICH, traumatic brain injury, etc., and have a MLS. Trans cranial ultrasonography was assessed by a single consultant (Neuro Critical Care Intensivist) who was blinded for the CT scan measurement. CT scan measurement of MLS was assessed by a neuroradiologist using standard guidelines, who was blinded for the TCS results of MLS. The finding of a MLS >0.5 cm in the CT scan was considered a significant MLS.

Results

A total of 31 patients were recruited for the study. MLS measured using CT was 0.91 ± 0.67 cm. MLS via TCS was 0.91 ± 0.66 cm. A significant MLS via TCS was found in 77.4%. Intraclass correlation coefficient (ICC) was calculated between CT-MLS and TCS MLS and obtained the value of ICC as 0.996, indicating an almost perfect agreement.

Conclusion

Patients after decompressive craniectomy may present as an ideal candidate to visualize intracerebral anatomy with a high resolution. TCS might be considered as an alternative to CT to measure MLS in decompressive craniectomy patients.

Cushing Index Based on Cushing Signs to Predict In-Hospital Death and Early Intervention for Minor Head Injury

A considerable number of patients with mild traumatic brain injury have been known to "talk and die." Serial neurological examinations, however, have been the only method of determining the necessity of repeat computed tomography (CT), and no validated method has been available to predict early deterioration of minor head injury. This study aimed to evaluate the association between hypertension and bradycardia, a classic sign of raised intracranial pressure (Cushing reflex) on hospital arrival and determine the clinical consequences of minor head injury after blunt trauma. We created a new Cushing Index (CI) by dividing the systolic blood pressure by the heart rate (equaling the inverse number of the Shock Index, a score for hemodynamic stability) and hypothesized that a high CI would predict surgical intervention for deterioration and in-hospital death among patients with minor head injury. To test our hypothesis, a retrospective observational study was conducted using a nationwide trauma database. Accordingly, adult blunt trauma with minor head injury (defined as a Glasgow Coma Scale of 13-15 and Abbreviated Injury Scale score of ≥2 in the head) who were transported directly from the scene by ambulances were included. Among the 338,744 trauma patients identified in the database, 38,844 were eligible for inclusion. A restricted cubic spline regression curve for risks of in-hospital death was created using the CI. Thereafter, the thresholds were determined based on inflection points of the curve, and patients were divided into low-, intermediate-, and high-CI groups. Patients with high CI showed significantly higher in-hospital mortality rates compared with those with intermediate CI (351 [3.0%] vs. 373 [2.3%]; odds ratio [OR] = 1.32 [1.14-1.53]; p < 0.001). Patients with high index also had a higher incidence of emergency cranial surgery within 24h after arrival than those with an intermediate CI (746 [6.4%] vs. 879 [5.4%]; OR = 1.20 [1.08-1.33]; p < 0.001). In addition, patients with low CI (equal to high Shock Index, meaning hemodynamically unstable) showed higher in-hospital death compared with those with intermediate CI (360 [3.3%] vs. 373 [2.3%]; p < 0.001). In conclusion, a high CI (high systolic blood pressure and low heart rate) on hospital arrival would be helpful in identifying patients with minor head injury who might experience deterioration and need close observation.

Neurointensive Care of Traumatic Brain Injury Patients Based on Coagulation and Fibrinolytic Parameter Monitoring

Coagulopathy, a common complication of traumatic brain injury (TBI), is characterized by a hypercoagulable state developing immediately after injury, with hyperfibrinolysis and bleeding tendency peaking 3 h after injury, followed by fibrinolysis shutdown. Reflecting this timeframe, the coagulation factor fibrinogen is first consumed and then degraded after TBI, its concentration rapidly decreasing by 3 h post-TBI. The fibrinolytic marker D-dimer reaches its maximum concentration at the same time. Hyperfibrinolysis in the acute phase of TBI is associated with poor prognosis via hematoma expansion. In the acute phase, the coagulation and fibrinolysis parameters must be monitored to determine the treatment strategy. The combination of D-dimer plasma level at admission and the level of consciousness upon arrival at the hospital can be used to predict the patients who will "talk and deteriorate." Fibrinogen and D-dimer levels should determine case selection and the amount of fresh frozen plasma required for transfusion. Surgery around 3 h after injury, when fibrinolysis and bleeding diathesis peak, should be avoided if possible. In recent years, attempts have been made to estimate the time of injury from the time course of coagulation and fibrinolysis parameter levels, which has been particularly useful in some cases of pediatric abusive head trauma patients.

A Prehospital Triage System to Detect Traumatic Intracranial Hemorrhage Using Machine Learning Algorithms

IMPORTANCE

An adequate system for triaging patients with head trauma in prehospital settings and choosing optimal medical institutions is essential for improving the prognosis of these patients. To our knowledge, there has been no established way to stratify these patients based on their head trauma severity that can be used by ambulance crews at an injury site.

OBJECTIVES

To develop a prehospital triage system to stratify patients with head trauma according to trauma severity by using several machine learning techniques and to evaluate the predictive accuracy of these techniques.

DESIGN, SETTING, AND PARTICIPANTS

This single-center retrospective cohort study was conducted by reviewing the electronic medical records of consecutive patients who were transported to Tokyo Medical and Dental University Hospital in Japan from April 1, 2018, to March 31, 2021. Patients younger than 16 years with cardiopulmonary arrest on arrival or with a significant amount of missing data were excluded.

MAIN OUTCOMES AND MEASURES

Machine learning-based prediction models to detect the presence of traumatic intracranial hemorrhage were constructed. The predictive accuracy of the models was evaluated with the area under the receiver operating curve (ROC-AUC), area under the precision recall curve (PR-AUC), sensitivity, specificity, and other representative statistics.

RESULTS

A total of 2123 patients (1527 male patients [71.9%]; mean [SD] age, 57.6 [19.8] years) with head trauma were enrolled in this study. Traumatic intracranial hemorrhage was detected in 258 patients (12.2%). Among several machine learning algorithms, extreme gradient boosting (XGBoost) achieved the mean (SD) highest ROC-AUC (0.78 [0.02]) and PR-AUC (0.46 [0.01]) in cross-validation studies. In the testing set, the ROC-AUC was 0.80, the sensitivity was 74.0% (95% CI, 59.7%-85.4%), and the specificity was 74.9% (95% CI, 70.2%-79.3%). The prediction model using the National Institute for Health and Care Excellence (NICE) guidelines, which was calculated after consultation with physicians, had a sensitivity of 72.0% (95% CI, 57.5%-83.8%) and a specificity of 73.3% (95% CI, 68.7%-77.7%). The McNemar test revealed no statistically significant differences between the XGBoost algorithm and the NICE guidelines for sensitivity or specificity (P = .80 and P = .55, respectively).

CONCLUSIONS AND RELEVANCE

In this cohort study, the prediction model achieved a comparatively accurate performance in detecting traumatic intracranial hemorrhage using only the simple pretransportation information from the patient. Further validation with a prospective multicenter data set is needed.

Delayed intracranial hemorrhage of patients with mild traumatic brain injury under antithrombotics on routine repeat CT scan: a systematic review and meta-analysis

In childhood, traumatic brain injury (TBI) poses the unique challenges of an injury to a developing brain and the dynamic pattern of recovery over time, inflicted TBI and its medicolegal ramifications. The mechanisms of injury vary with age, as do the mechanisms that lead to the primary brain injury. As it is common, and is the leading cause of death and disability in the USA and Canada, prevention is the key, and we may need increased legislation to facilitate this. Despite its prevalence, there is an almost urgent need for research to help guide the optimal management and improve outcomes.

Indeed, contrary to common belief, children with severe TBI have a worse outcome and many of the consequences present in teenage years or later. The treatment needs, therefore, to be multifaceted and starts at the scene of the injury and extends into the home and school. In order to do this, the care needs to be multidisciplinary from specialists with a specific interest in TBI and to involve the family, and will often span many decades.

A Robust, Fully Automatic Detection Method and Calculation Technique of Midline Shift in Intracranial Hemorrhage and Its Clinical Application

A midline shift (MLS) is an important clinical indicator for intracranial hemorrhage. In this study, we proposed a robust, fully automatic neural network-based model for the detection of MLS and compared it with MLSs drawn by clinicians; we also evaluated the clinical applications of the fully automatic model. We recruited 300 consecutive non-contrast CT scans consisting of 7269 slices in this study. Six different types of hemorrhage were included. The automatic detection of MLS was based on modified Keypoint R-CNN with keypoint detection followed by training on the ResNet-FPN-50 backbone. The results were further compared with manually drawn outcomes and manually defined keypoint calculations. Clinical parameters, including Glasgow coma scale (GCS), Glasgow outcome scale (GOS), and 30-day mortality, were also analyzed. The mean absolute error for the automatic detection of an MLS was 0.936 mm compared with the ground truth. The interclass correlation was 0.9899 between the automatic method and MLS drawn by different clinicians. There was high sensitivity and specificity in the detection of MLS at 2 mm (91.7%, 80%) and 5 mm (87.5%, 96.7%) and MLSs greater than 10 mm (85.7%, 97.7%). MLS showed a significant association with initial poor GCS and GCS on day 7 and was inversely correlated with poor 30-day GOS (p < 0.001). In conclusion, automatic detection and calculation of MLS can provide an accurate, robust method for MLS measurement that is clinically comparable to the manually drawn method.

Coagulopathy and Traumatic Brain Injury: Overview of New Diagnostic and Therapeutic Strategies

Coagulopathy is a common sequela of traumatic brain injury. Consumptive coagulopathy and secondary hyperfibrinolysis are associated with hypercoagulability. In addition, fibrinolytic pathways are hyperactivated as a result of vascular endothelial cell damage in the injured brain. Coagulation and fibrinolytic parameters change dynamically to reflect these pathologies. Fibrinogen is consumed and degraded after injury, with fibrinogen concentrations at their lowest 3-6 h after injury. Hypercoagulability causes increased fibrinolytic activity, and plasma levels of D-dimer increase immediately after traumatic brain injury, reaching a maximum at 3 h. Owing to disseminated intravascular coagulation in the presence of fibrinolysis, the bleeding tendency is highest within the first 3 h after injury, and often a condition called “talk and deteriorate” occurs. In neurointensive care, it is necessary to measure coagulation and fibrinolytic parameters such as fibrinogen and D-dimer routinely to predict and prevent the development of coagulopathy and its negative outcomes. Currently, the only evidence-based treatment for traumatic brain injury with coagulopathy is tranexamic acid in the subset of patients with mild-to-moderate traumatic brain injury. Coagulation and fibrinolytic parameters should be closely monitored, and treatment should be considered on a patient-by-patient basis.

Rapid Detection of Significant Traumatic Brain Injury Requiring Emergency Intervention

Moderate and severe traumatic brain injuries (TBI) are a major cause of severe morbidity and mortality; rapid diagnosis and management allow secondary injury to be minimized. Traumatic brain injury is only one of many potential causes of altered mental status; head computed tomography (HCT) is used to definitively diagnose TBI. Despite its widespread use and obvious importance, interpretation of HCT images is rarely covered by formal didactics during general surgery or even acute care surgery training. The schema illustrated here may be applied in a rapid and reliable fashion to HCT images, expediting the diagnosis of clinically significant traumatic brain injury that warrants emergent medical and surgical therapies to reduce intracranial pressure. It consists of 7 normal anatomic structures (cerebrospinal fluid around the brain stem, open fourth ventricle, "baby's butt," "Mickey Mouse ears," absence of midline shift, sulci and gyri, and gray-white differentiation). These 7 features can be seen even as the CT scanner obtains images, allowing the trauma team to expedite medical management of intracranial hypertension and pursue neurosurgical consultation prior to radiologic interpretation if the features are abnormal.

Second Impact Syndrome. Myth or reality?

INTRODUCTION

Second impact syndrome (SIS) is a devastating condition occurring in sport-induced mild brain injury. SIS is drastically defined by anamnestic, clinical and radiological criteria, which is unusual in the field of cranial traumatology. The purpose of this study was to provide a literature review of this syndrome.

MATERIAL AND METHODS

We conducted a literature review of all published studies on PubMed. The keywords were "second impact syndrome and catastrophic head injury", "second impact syndrome and sport", "repeat concussion and catastrophic brain injury", "catastrophic head injury and concussion", "catastrophic head injury", "concussion and second impact syndrome", "concussion and repetitive head injury".

RESULTS

Eighty-two full-text articles were assessed for eligibility. Finally, 41 studies were included in qualitative synthesis and 21 were included in quantitative synthesis.

DISCUSSION

The number of cases reported in the literature was extremely small compared to the population at risk, i.e., the number of athletes exposed to repeated concussions. SIS was similar to talk and die syndrome, with which it shares certain characteristics. If we consider SIS according to "talk and deteriorate tables", it opens up interesting perspectives because they are specific in children and adolescents. Taking into account the scarcity of this syndrome, one may question whether athlete-intrinsic features may be involved in at least some cases of SIS. On a pathophysiological level, many explanations remained unsatisfactory because they were unable to explain all the clinical phenomena and observed lesions. Triggering the trigeminocardiac reflex is a crucial element in explaining the sequence of clinical events. Its association with a state of neurogenic inflammation provides an almost complete explanation for this particular condition. Finally, on a practical level, a concussion occurring during the playing of a sport must be considered as any other injury before allowing a return to play.

Impact of a posttraumatic cerebral infarction on outcome in patients with TBI: the Italian multicenter cohort INCEPT study

BACKGROUND

Post-traumatic cerebral infarction (PTCI) is common after traumatic brain injury (TBI). It is unclear what the occurrence of a PTCI is, how it impacts the long-term outcome, and whether it adds incremental prognostic value to established outcome predictors.

METHODS

This was a prospective multicenter cohort study of moderate and severe TBI patients. The primary objective was to evaluate if PTCI was an independent risk factor for the 6-month outcome assessed with the Glasgow Outcome Scale (GOS). We also assessed the PTCI occurrence and if it adds incremental value to the International Mission for Prognosis and Clinical Trial design in TBI (IMPACT) core and extended models.

RESULTS

We enrolled 143 patients, of whom 47 (32.9%) developed a PTCI. In the multiple ordered logistic regression, PTCI was retained in both the core and extended IMPACT models as an independent predictor of the GOS. The predictive performances increased significantly when PTCI was added to the IMPACT core model (AUC = 0.73, 95% C.I. 0.66-0.82; increased to AUC = 0.79, 95% CI 0.71-0.83, p = 0.0007) and extended model (AUC = 0.74, 95% C.I. 0.65-0.81 increased to AUC = 0.80, 95% C.I. 0.69-0.85; p = 0.00008). Patients with PTCI showed higher ICU mortality and 6-month mortality, whereas hospital mortality did not differ between the two groups.

CONCLUSIONS

PTCI is a common complication in patients suffering from a moderate or severe TBI and is an independent risk factor for long-term disability. The addition of PTCI to the IMPACT core and extended predictive models significantly increased their performance in predicting the GOS.

TRIAL REGISTRATION

The present study was registered in ClinicalTrial.gov with the ID number NCT02430324.

Automatic Midline Shift Detection in Traumatic Brain Injury

Fast and accurate midline shift (MLS) estimation has a significant impact on diagnosis and treatment of patients with Traumatic Brain Injury (TBI). In this paper, we propose an automated method to calculate the amount of shift in the midline structure of TBI patients. The MLS values were annotated by a neuroradiologist. We first select a number of slices among all the slices in a CT scan based on metadata as well as information extracted from the images. After the slice selection, we propose an efficient segmentation technique to detect the ventricles. We use the ventricular geometric patterns to calculate the actual midline and also anatomical information to detect the ideal midline. The distance between these two lines is used as an estimate of MLS. The proposed methods are applied on a TBI dataset where they show a significant improvement of the the proposed method upon existing approach.

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage

BACKGROUND

Patients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions.

METHODS

This was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention.

RESULTS

Of these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2-7.2 95 CI) had neurological decline, 73 (7.5% 5.9-9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5-7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1-0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305.

CONCLUSIONS

RHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.

Blast-induced traumatic brain injury: the experience from a level I trauma center in southern Thailand

OBJECTIVE

In the ongoing conflict in southern Thailand, the improvised explosive device (IED) has been a common cause of blast-induced traumatic brain injury (bTBI). The authors investigated the particular characteristics of bTBI and the factors associated with its clinical outcome.

METHODS

A retrospective cohort study was conducted on all patients who had sustained bTBI between 2009 and 2017. Collected data included clinical characteristics, intracranial injuries, and outcomes. Factors analysis was conducted using a forest plot.

RESULTS

During the study period, 70 patients met the inclusion criteria. Fifty individuals (71.4%) were military personnel. One-third of the patients (32.9%) suffered moderate to severe bTBI, and the rate of intracerebral injuries on brain CT was 65.7%. Coup contusion was the most common finding, and primary blast injury was the most common mechanism of blast injury. Seventeen individuals had an unfavorable outcome (Glasgow Outcome Scale score 1–3), and the overall mortality rate for bTBI was 11.4%. In the univariate analysis, factors associated with an unfavorable outcome were preoperative coagulopathy, midline shift of the brain ≥ 5 mm, basal cistern effacement, moderate to severe TBI, hypotension, fixed and dilated pupils, surgical site infection, hematocrit < 30% on admission, coup contusion, and subdural hematoma. In the multivariable analysis, midline shift ≥ 5 mm (OR 29.1, 95% CI 2.5–328.1) and coagulopathy (OR 28.7, 95% CI 4.5–180.3) were the only factors predicting a poor outcome of bTBI.

CONCLUSIONS

bTBIs range from mild to severe. Midline shift and coagulopathy are treatable factors associated with an unfavorable outcome. Hence, in cases of bTBI, reversing an abnormal coagulogram is required as soon as possible to improve clinical outcomes. The management of brain shift needs further study.

Reliability of Glasgow Coma Score in pediatric trauma patients

BACKGROUND

Discordant assessments of Glasgow Coma Score (GCS) following trauma can result in inappropriate triage. This study sought to determine the reliability of prehospital GCS compared to emergency department (ED) GCS.

METHODS

We conducted a retrospective review of traumas from 01/2000 to 12/2015 at a Level-1 pediatric trauma center. We evaluated reliability between field and ED GCS using Pearson's correlation. We ascertained the difference between prehospital and ED GCS (delta-GCS). Associations between patient characteristics and delta-GCS were modeled using Poisson and linear regression, adjusting for demographic and clinical covariates.

RESULTS

We identified 5306 patients. Pearson's correlation for GCS measurements was 0.57 for ages 0-3, and 0.67-0.77 for other age groups. Mean delta-GCS was highest for age<3years (0.95, SD=2.4). Poisson regression demonstrated that compared to children 0-3years, higher age was associated with lower delta-GCS (RR 0.65 95% CI 0.56-0.74). Linear regression showed that in those with a delta-GCS, more severe injury (higher ISS, worse ED disposition) and older age were associated with a negative change, signifying decline in score.

CONCLUSIONS

GCS is generally unreliable in pediatric trauma patients aged 0-3years, particularly the verbal score component. This may impact accuracy of triage priority for pediatric trauma patients.

LEVEL OF EVIDENCE

III, Prognostic.

Brain Midline Shift Measurement and Its Automation: A Review of Techniques and Algorithms

Midline shift (MLS) of the brain is an important feature that can be measured using various imaging modalities including X-ray, ultrasound, computed tomography, and magnetic resonance imaging. Shift of midline intracranial structures helps diagnosing intracranial lesions, especially traumatic brain injury, stroke, brain tumor, and abscess. Being a sign of increased intracranial pressure, MLS is also an indicator of reduced brain perfusion caused by an intracranial mass or mass effect. We review studies that used the MLS to predict outcomes of patients with intracranial mass. In some studies, the MLS was also correlated to clinical features. Automated MLS measurement algorithms have significant potentials for assisting human experts in evaluating brain images. In symmetry-based algorithms, the deformed midline is detected and its distance from the ideal midline taken as the MLS. In landmark-based ones, MLS was measured following identification of specific anatomical landmarks. To validate these algorithms, measurements using these algorithms were compared to MLS measurements made by human experts. In addition to measuring the MLS on a given imaging study, there were newer applications of MLS that included comparing multiple MLS measurement before and after treatment and developing additional features to indicate mass effect. Suggestions for future research are provided.

Neurotrauma

Traumatic brain injury remains a major cause of morbidity and mortality throughout the world, affecting young and old alike. Pathologic data have been developed through observations of human autopsies and developing animal models to investigate mechanisms, although animal models do not represent the polypathology of human brain injury and there are likely to be significant differences in the anatomic basis of injury and cellular responses between species. Traumatic brain injury can be defined pathologically as either focal or diffuse, and can be considered to be either primary, directly related to the force associated with the neurotrauma, or secondary, developing as a downstream consequence of the neurotrauma. While neuropathology has traditionally focused on severe head injury, there is increasing recognition of the long-term consequences of traumatic brain injury, particularly repetitive mild traumatic brain injury, and a possible long-term association with chronic traumatic encephalopathy.

Symptomatic Acute-on-Chronic Subdural Hematoma: A Clinicopathological Study

The pathophysiology of acute-on-chronic subdural hematoma (ACSDH) is complex and incompletely understood. Evidence to date indicates that the overall process is initiated by rotational force with movement of the brain inside the skull, which exerts tensile strain and rupture of bridging veins, leading in turn to acute hemorrhage in the subdural potential space. This is followed by the proliferation of mesenchymal elements with angiogenesis and inflammation, which in turn becomes a substrate for repeated hemorrhage and expansion of the lesion. Given the prevalence of traumatic subdural processes in the forensic setting and the importance of proper assessment of timing, etiology, risk factors, and clinicopathological correlation, we studied 47 patients presenting to the University of Maryland Shock Trauma Center, all of whom underwent craniotomy with resection of the outer membrane due to symptomatic ACSDH. The surgically resected tissue was examined for histopathologic features in all cases. Our findings highlight that ACSDH is a condition precipitated by trauma that affects middle-aged and older adults, is relatively indolent, is unilateral or asymmetric, and has a low in-hospital mortality rate. Pathological analysis demonstrates a substantial outer membrane in all cases with varying degrees of inflammation and organization that cannot be precisely dated as a function of clinical presentation. The extrapolation of adult ACSDH to mixed acute and chronic subdural hemorrhage in the pediatric setting is problematic due to substantial differences in clinical presentation, severity of underlying brain injury, gross and microscopic findings, and outcome.

Care of Traumatic Conditions in an Observation Unit

Patients presenting to the emergency department with certain traumatic conditions can be managed in observation units. The evidence base supporting the use of observation units to manage injured patients is smaller than the evidence base supporting the management of medical conditions in observation units. The conditions that are eligible for management in an observation unit are not limited to those described in this article, and investigators should continue to identify types of conditions that may benefit from this type of health care delivery.

According to which factors in severe traumatic brain injury craniectomy could be beneficial

BACKGROUND

To investigate the clinical outcome at 101 patients undergoing decompressive craniectomy (DC) after severe traumatic brain injury (TBI).

METHODS

Age, Glasgow Coma Scale (GCS) at the time of intubation, and the intraoperative intracranial pressure (ICP) were recorded. Formal DC was performed in all cases and the square surface of bone flap was calculated in cm(2) based on the length and the width from computed tomography scan.

RESULTS

The difference of good neurological recovery (Glasgow outcome score 4-5), between patients with ICP ≤20 mmHg, GCS ≥5, age ≤60 years, and bone flap ≥130 cm(2) and those with ICP >20 mmHg, GCS <5, age >60 years, and bone flap <130 cm(2), was statistically significant.

CONCLUSION

Although the application of DC in severe TBI is controversial and the population in this study is small, our study demonstrates the threshold of the specific factors (patient age, ICP and GCS on the day of the surgery and the size of the bone flap) which may help in the decision of performing DC. Furthermore, this study proves that the different combinations and mainly at the same time involvement of all prognostic parameters (age <60, GCS <5, bone flap ≥130 cm(2), and ICP ≤20 at time of DC surgery) allow a better outcome.

Time Course of Coagulation and Fibrinolytic Parameters in Patients with Traumatic Brain Injury

Traumatic brain injury (TBI) has long been associated with coagulopathy; however, the time course of coagulation/fibrinolytic parameters in the acute phase of TBI remains unclear. The purpose of the study was to analyze the time course of coagulation/fibrinolytic parameters in the acute phase of TBI and to elucidate parameter relationships to prognosis. We retrospectively evaluated 234 patients with severe isolated TBI with initial blood samples obtained no more than 1 h after injury. Platelet count, prothrombin time, activated partial thromboplastin time (aPTT), plasma levels of fibrinogen, and D-dimer were measured on arrival in the emergency department and 3, 6, and 12 h after injury. Multivariate logistic regression analysis was performed to identify risk factors for poor prognosis at each time point. From hospital admission to 12 h after injury, an elevated D-dimer level was a significant negative prognostic indicator (admission: p < 0.0001; 3 h after injury: p = 0.0005; 6 h after injury: p = 0.005; 12 h after injury: p = 0.0009). An upward trend of aPTT on admission and 3 h after injury was also a significant negative prognostic indicator (admission: p = 0.0011; 3 h after injury: p = 0.013). On multivariate logistic regression analysis, which included all initial variables, independent risk factors for poor prognosis included older age (p = 0.0005), low Glasgow Coma Scale score (p < 0.0001), high Abbreviated Injury Score (p = 0.015), aPTT >30.2 sec (p = 0.019), and elevated D-dimer level (p = 0.0005). We concluded that D-dimer is the best coagulation/fibrinolytic parameter to monitor for prediction of outcome.

Traumatic brain injury, coronary atherosclerosis and cardiovascular mortality

BACKGROUND

Traumatic-brain-injury (TBI) is a devastating-condition resulting in cerebral edema and ischemia. This study investigates the association of mild-TBI (mTBI) to sub-clinical atherosclerosis and cardiovascular (CV) mortality.

METHODS

Five hundred and forty-three veterans without known coronary artery disease or diagnosed mental disorder, who underwent coronary artery calcium (CAC) scanning for clinical indications, were followed for a median of 4-years. Veterans' medical diagnoses and neuropsychiatric health status (mTBI vs non-mTBI) were evaluated using VA electronic medical records. CAC was defined as 0, 1-100, 101-400 and 400+.

RESULTS

CAC was higher in mTBI, compared to without-mTBI (p < 0.05). TBI was more prevalent with the-severity of CAC (p < 0.05). Regression-analyses revealed that mTBI is an independent-predictor of CAC (p < 0.01). The CV mortality rate was 25% in mTBI and 10.5% in without-mTBI (p = 0.0001). Multivariable survival regression analyses revealed a significant-association between mTBI and CAC, with increased-risk of CV mortality (p < 0.05). The hazard-ratio of CV mortality was 5.25 in mTBI & CAC > 0, compared to without-mTBI & CAC = 0 (p < 0.05). The risk of CV-mortality was 2.25 for mTBI & CAC = 1-100, 4.93 for mTBI & CAC = 101-400 and 7.06 for mTBI & CAC ≥ 400, compared to matched CAC-categories without-mTBI (p < 0.05). The area under ROC curve to predict CV mortality was 0.64 for mTBI, 0.69 for mTBI & PTSD, 0.85 for mTBI & CAC > 0 and 0.92 for the combination. The prognostication of mTBI to predict CV mortality is superior to the Framingham risk score. Also the combination of mTBI & PTSD provided incremental prognostic values to predict CV mortality (p < 0.05).

CONCLUSIONS

mTBI is associated with the severity of sub-clinical coronary atherosclerosis and independently predicts CV mortality.

Day of injury CT and late MRI findings: Cognitive outcome in a paediatric sample with complicated mild traumatic brain injury

OBJECTIVES

Complicated mild traumatic brain injury (mTBI) or cmTBI is based on the presence of visibly identifiable brain pathology on the day-of-injury computed tomography (CT) scan. In a paediatric sample the relation of DOI CT to late MRI findings and neuropsychological outcome was examined.

METHODS

MRI (>12 months) was obtained in paediatric cmTBI patients and a sample of orthopaedically injured (OI) children. Those children with positive imaging findings (MRI+) were quantitatively compared to those without (MRI-) or with the OI sample. Groups were also compared in neurocognitive outcome from WASI sub-tests and the WISC-IV Processing Speed Index (PSI), along with the Test of Everyday Attention for Children (TEA-Ch) and a parent-rated behavioural functioning measure (ABAS-II).

RESULTS

Despite the MRI+ group having significantly more DOI CT findings than the MRI- group, no quantitative differences were found. WASI Vocabulary and Matrix Reasoning scores were significantly lower, but not PSI, TEA-Ch or ABAS-II scores. MRI+ and MRI- groups did not differ on these measures.

CONCLUSIONS

Heterogeneity in the occurrence of MRI-identified focal pathology was not associated with uniform changes in quantitative analyses of brain structure in cmTBI. Increased number of DOI CT abnormalities was associated with lowered neuropsychological performance.

Back to the Bedside: Developing a Bedside Aid for Concussion and Brain Injury Decisions in the Emergency Department

Context:

Current information-rich electronic health record (EHR) interfaces require large, high-resolution screens running on desktop computers. This interface compromises the provider’s already limited time at the bedside by physically separating the patient from the doctor. The case study presented here describes a patient-centered clinical decision support (CDS) design process that aims to bring the physician back to the bedside by integrating a patient decision aid with CDS for shared use by the patient and provider on a touchscreen tablet computer for deciding whether or not to obtain a CT scan for minor head injury in the emergency department, a clinical scenario that could benefit from CDS but has failed previous implementation attempts.

Case Description:

This case study follows the user-centered design (UCD) approach to build a bedside aid that is useful and usable, and that promotes shared decision-making between patients and their providers using a tablet computer at the bedside. The patient-centered decision support design process focuses on the prototype build using agile software development, but also describes the following: (1) the requirement gathering phase including triangulated qualitative research (focus groups and cognitive task analysis) to understand current challenges, (2) features for patient education, the physician, and shared decision-making, (3) system architecture and technical requirements, and (4) future plans for formative usability testing and field testing.

Lessons Learned:

We share specific lessons learned and general recommendations from critical insights gained in the patient-centered decision support design process about early stakeholder engagement, EHR integration, external expert feedback, challenges to two users on a single device, project management, and accessibility.

Conclusions:

Successful implementation of this tool will require seamless integration into the provider’s workflow. This protocol can create an effective interface for shared decision-making and safe resource reduction at the bedside in the austere and dynamic clinical environment of the ED and is generalizable for these purposes in other clinical environments as well.

Prognostic Value of Evoked Responses and Event-Related Brain Potentials in

The behaviourally unresponsive patient, unable to exhibit the presence of cognition, constitutes a conundrum for health care specialists. Prognostic uncertainty impedes accurate management decisions and the application of ethical principles. An early, reliable prognosis is highly desirable. In this review investigations studying comatose patients with coma of different etiologies were selected. It is concluded that objective prognostication is enhanced by the use of electrophysiological tests. Persistent abnormalities of brainstem auditory evoked potentials and short-latency somatosensory evoked potentials reliably indicate the likelihood of irreversible neurological deficit or death. Meanwhile, the presence of “cognitive” event-related brain potentials (e.g., P300 and mismatch negativity) reflects the functional integrity of higher level information processing and, therefore, the likelihood of capacity for cognition. An approach that combines clinical and electrophysiological values provides optimal prediction of outcome and level of disability.

Delayed neurological deterioration after mild head injury: cause, temporal course, and outcomes

BACKGROUND

Mild head injury (MHI) complicated by an intracranial hemorrhage (ICH) is a common cause of hospital admission after head trauma. Most patients are treated nonoperatively, remain neurologically stable, and are discharged uneventfully. However, a small percentage of patients suffer delayed neurological deterioration (DND). Little is known about the characteristics of DND after an MHI complicated by ICH.

OBJECTIVE

To identify the cause, temporal course, and outcomes of patients who deteriorated neurologically after presenting with MHI and ICH.

METHODS

A retrospective review was performed of all adult patients presenting over 54 consecutive months with MHI and ICH. Patients who were treated nonoperatively after initial head computed tomography and had a subsequent DND (Glasgow Coma Scale score decrease ≥2) were identified. Demographics, neurological status, clinical course, radiographic findings, and outcome data were collected.

RESULTS

Over 54 months, 757 patients with MHI plus ICH were admitted for observation; of these, 31 (4.1%) experienced DND. Eighty-seven percent of patients deteriorated within 24 hours after admission. Twenty-one patients (68%) deteriorated as a result of progressive intracranial hemorrhage, and 10 patients (32%) deteriorated as a result of medical causes. Seven patients (23%) died. Variables significantly associated with mortality included age > 60 years, coagulopathy, and change in Marshall computed tomography classification.

CONCLUSION

The incidence of delayed neurological deterioration after MHI with ICH is low and usually occurs within 24 hours after admission. It results in significant morbidity and mortality if it is the result of progressive intracranial hemorrhage. Further research is needed to identify risk factors that can allow early detection and improve outcomes in these patients.

Role of hormonal levels on hospital mortality for male patients with severe traumatic brain injury

INTRODUCTION

Changes in hormone blood levels during the acute phase of traumatic brain injury (TBI) have been described in the literature. The objective was to investigate the association among several hormones plasma levels in the acute phase of severe TBI and the hospital mortality rate of male patients.

METHODS

The independent association among plasma levels of TSH, LH, FSH, GH, free T4, cortisol, IGF-1 and total testosterone was measured 10 hours and 30 hours after severe TBI and the hospital mortality of 60 consecutive male patients was evaluated.

RESULTS

At least one hormonal level abnormality was demonstrated in 3.6-73.1% of patients. The multiple logistic regressions showed a trend for an independent association among hospital mortality and normal or elevated LH levels measured at 10 hours (OR = 3.7, 95% CI = 0.8-16.3, p = 0.08) and 30 hours (OR = 3.9, 95% CI = 0.9-16.7, p = 0.06). Admission with abnormal pupils and a lower Glasgow Coma Score also were independently associated with hospital mortality.

CONCLUSION

The hormonal changes are frequent in the acute phase of severe TBI. The hormones plasma levels, excepting the LH, are not highly consistent with the hospital mortality of male patients.

Neurotraumatology

Neurotraumatology has its roots in ancient history, but its modern foundations are the physical examination, imaging to localize the pathology, and thoughtful medical and surgical decision making. The neurobiology of cranial and spinal injury is similar, with the main goal of therapies being to limit secondary injury. Brain injury treatment focuses on minimizing parenchymal swelling within the confined cranial vault. Spine injury treatment has the additional consideration of spinal coumn stability. Current guidelines for non-operative and operative management are reviewed in this chapter.

Factors correlating with delayed trauma center admission following traumatic brain injury

BACKGROUND

Delayed admission to appropriate care has been shown increase mortality following traumatic brain injury (TBI). We investigated factors associated with delayed admission to a hospital with neurosurgical expertise in a cohort of TBI patients in the intensive care unit (ICU).

METHODS

A retrospective analysis of all TBI patients treated in the ICUs of Helsinki University Central Hospital was carried out from 1.1.2009 to 31.12.2010. Patients were categorized into two groups: direct admission and delayed admission. Patients in the delayed admission group were initially transported to a local hospital without neurosurgical expertise before inter-transfer to the designated hospital. Multivariate logistic regression was utilized to identify pre-hospital factors associated with delayed admission.

RESULTS

Of 431 included patients 65% of patients were in the direct admission groups and 35% in the delayed admission groups (median time to admission 1:07h, IQR 0:52-1:28 vs. 4:06h, IQR 2:53-5:43, p <0.001). In multivariate analysis factors increasing the likelihood of delayed admission were (OR, 95% CI): male gender (3.82, 1.60-9.13), incident at public place compared to home (0.26, 0.11-0.61), high energy trauma (0.05, 0.01-0.28), pre-hospital physician consultation (0.15, 0.06-0.39) or presence (0.08, 0.03-0.22), hypotension (0.09, 0.01-0.93), major extra cranial injury (0.17, 0.05-0.55), abnormal pupillary light reflex (0.26, 0.09-0.73) and severe alcohol intoxication (12.44, 2.14-72.38). A significant larger proportion of patients in the delayed admission group required acute craniotomy for mass lesion when admitted to the neurosurgical hospital (57%, 21%, p< 0.001). No significant difference in 6-month mortality was noted between the groups (p= 0.814).

CONCLUSION

Delayed trauma center admission following TBI is common. Factors increasing likelihood of this were: male gender, incident at public place compared to home, low energy trauma, absence of pre-hospital physician involvement, stable blood pressure, no major extra cranial injuries, normal pupillary light reflex and severe alcohol intoxication. Focused educational efforts and access to physician consultation may help expedite access to appropriate care in TBI patients.

Introduction of the Uppsala Traumatic Brain Injury register for regular surveillance of patient characteristics and neurointensive care management including secondary insult quantification and clinical outcome

BACKGROUND

To improve neurointensive care (NIC) and outcome for traumatic brain injury (TBI) patients it is crucial to define and monitor indexes of the quality of patient care. With this purpose we established the web-based Uppsala TBI register in 2008. In this study we will describe and analyze the data collected during the first three years of this project.

METHODS

Data from the medical charts were organized in three columns containing: 1) Admission data; 2) Data from the NIC period including neurosurgery, type of monitoring, treatment, complications, neurological condition at discharge, and the amount of secondary insults; 3) Outcome six months after injury. Indexes of the quality of care implemented include: 1) Index of improvement; 2) Index of change; 3) The percentages of 'Talk and die' and 'Talk and deteriorate' patients.

RESULTS

Altogether 314 patients were included 2008-2010: 66 women and 248 men aged 0-86 years. Automatic reports showed that the proportion of patients improving during NIC varied between 80% and 60%. The percentage of deteriorated patients was less than 10%. The percentage of Talk and die/Talk and deteriorate cases was <1%. The mean Glasgow Coma Score (Motor) improved from 5.04 to 5.68 during the NIC unit stay. The occurrences of secondary insults were less than 5% of good monitoring time for intracranial pressure (ICP) >25 mmHg, cerebral perfusion pressure (CPP) <50 mmHg, and systolic blood pressure <100 mmHg. Favorable outcome was achieved by 64% of adults.

CONCLUSION

The Uppsala TBI register enables the routine monitoring of NIC quality indexes.

What is the incidence of intracranial bleeding in patients with mild traumatic brain injury? A retrospective study in 3088 Canadian CT head rule patients

Objective. Only limited data exists in terms of the incidence of intracranial bleeding (ICB) in patients with mild traumatic brain injury (MTBI). Methods. We retrospectively identified 3088 patients (mean age 41 range (7–99) years) presenting with isolated MTBI and GCS 14-15 at our Emergency Department who had undergone cranial CT (CCT) between 2002 and 2011. Indication for CCT was according to the “Canadian CT head rules.” Patients with ICB were either submitted for neurosurgical treatment or kept under surveillance for at least 24 hours. Pearson's correlation coefficient was used to correlate the incidence of ICB with age, gender, or intake of coumarins, platelet aggregation inhibitors, or heparins. Results. 149 patients (4.8%) had ICB on CCT. No patient with ICB died or deteriorated neurologically. The incidence of ICB increased with age and intake of anticoagulants without clinically relevant correlation (R = 0.11; P < 0.001; R = −0.06; P < 0.001). Conclusion. Our data show an incidence of 4.8% for ICB after MTBI. However, neurological deterioration after MTBI seems to be rare, and the need for neurosurgical intervention is only required in selected cases. The general need for CCT in patients after MTBI is therefore questionable, and clinical surveillance may be sufficient when CCT is not available.

Prognosis in severe brain injury

BACKGROUND

The prediction of neurologic outcome is a fundamental concern in the resuscitation of patients with severe brain injury.

OBJECTIVE

To provide an evidence-based update on neurologic prognosis following traumatic brain injury and hypoxic-ischemic encephalopathy after cardiac arrest.

DATA SOURCE

Search of the PubMed database and manual review of bibliographies from selected articles to identify original data relating to prognostic methods and outcome prediction models in patients with neurologic trauma or hypoxic-ischemic encephalopathy.

DATA SYNTHESIS AND CONCLUSION

Articles were scrutinized regarding study design, population evaluated, interventions, outcomes, and limitations. Outcome prediction in severe brain injury is reliant on features of the neurologic examination, anatomical and physiological changes identified with CT and MRI, abnormalities detected with electroencephalography and evoked potentials, and physiological and biochemical derangements at both the brain and systemic levels. Use of such information in univariable association studies generally lacks specificity in classifying neurologic outcome. Furthermore, the accuracy of established prognostic classifiers may be affected by the introduction of outcome-modifying interventions, such as therapeutic hypothermia following cardiac arrest. Although greater specificity may be achieved with scoring systems derived from multivariable models, they generally fail to predict outcome with sufficient accuracy to be meaningful at the single patient level. Discriminative models which integrate knowledge of genetic determinants and biologic processes governing both injury and repair and account for the effects of resuscitative and rehabilitative care are needed.

A prospective, randomized Phase II clinical trial to evaluate the effect of combined hyperbaric and normobaric hyperoxia on cerebral metabolism, intracranial pressure, oxygen toxicity, and clinical outcome in severe traumatic brain injury

OBJECT

Preclinical and clinical investigations indicate that the positive effect of hyperbaric oxygen (HBO2) for severe traumatic brain injury (TBI) occurs after rather than during treatment. The brain appears better able to use baseline O2 levels following HBO2 treatments. In this study, the authors evaluate the combination of HBO2 and normobaric hyperoxia (NBH) as a single treatment.

METHODS

Forty-two patients who sustained severe TBI (mean Glasgow Coma Scale [GCS] score 5.7) were prospectively randomized within 24 hours of injury to either: 1) combined HBO2/NBH (60 minutes of HBO2 at 1.5 atmospheres absolute [ATA] followed by NBH, 3 hours of 100% fraction of inspired oxygen [FiO2] at 1.0 ATA) or 2) control, standard care. Treatments occurred once every 24 hours for 3 consecutive days. Intracranial pressure, surrogate markers for cerebral metabolism, and O2 toxicity were monitored. Clinical outcome was assessed at 6 months using the sliding dichotomized Glasgow Outcome Scale (GOS) score. Mixed-effects linear modeling was used to statistically test differences between the treatment and control groups. Functional outcome and mortality rates were compared using chi-square tests.

RESULTS

There were no significant differences in demographic characteristics between the 2 groups. In comparison with values in the control group, brain tissue partial pressure of O2 (PO2) levels were significantly increased during and following combined HBO2/NBH treatments in both the noninjured and pericontusional brain (p < 0.0001). Microdialysate lactate/pyruvate ratios were significantly decreased in the noninjured brain in the combined HBO2/NBH group as compared with controls (p < 0.0078). The combined HBO2/NBH group's intracranial pressure values were significantly lower than those of the control group during treatment, and the improvement continued until the next treatment session (p < 0.0006). The combined HBO2/NBH group's levels of microdialysate glycerol were significantly lower than those of the control group in both noninjured and pericontusional brain (p < 0.001). The combined HBO2/NBH group's level of CSF F2-isoprostane was decreased at 6 hours after treatment as compared with that of controls, but the difference did not quite reach statistical significance (p = 0.0692). There was an absolute 26% reduction in mortality for the combined HBO2/NBH group (p = 0.048) and an absolute 36% improvement in favorable outcome using the sliding dichotomized GOS (p = 0.024) as compared with the control group.

CONCLUSIONS

In this Phase II clinical trial, in comparison with standard care (control treatment) combined HBO2/NBH treatments significantly improved markers of oxidative metabolism in relatively uninjured brain as well as pericontusional tissue, reduced intracranial hypertension, and demonstrated improvement in markers of cerebral toxicity. There was significant reduction in mortality and improved favorable outcome as measured by GOS. The combination of HBO2 and NBH therapy appears to have potential therapeutic efficacy as compared with the 2 treatments in isolation. CLINICAL TRIAL REGISTRATION NO.: NCT00170352 (ClinicalTrials.gov).

CT overuse for mild traumatic brain injury

BACKGROUND

Multiple, validated, evidence-based guidelines exist to inform the appropriate use of computed tomography (CT) to differentiate mild traumatic brain injury (MTBI) from clinically important brain injury and to prevent the overuse of CT. Yet, CT use is growing rapidly, potentially exposing patients to unnecessary ionizing radiation risk and costs. A study was conducted to quantify the overuse of CT in MTBI on the basis of current guideline recommendations.

METHODS

A retrospective analysis of secondary data from a prospective observational study was undertaken at an urban, Level I emergency department (ED) with more than 90,000 visits per year. For adult patients with minor head injury receiving CT imaging at the discretion of the treating physician, the proportion of cases meeting criteria for CT on the basis of the Canadian CT Head Rule (CCHR), American College of Emergency Physicians (ACEP) Clinical Policy, New Orleans Criteria (NOC), and National Institute for Health and Clinical Excellence (NICE) guidelines was reported.

RESULTS

All 346 patients enrolled in the original study were included in the analysis. The proportion of cases meeting criteria for CT for each of the guidelines was: CCHR 64.7% (95% confidence interval [CI], 0.60-0.70), ACEP 74.3% (95% CI, 0.70-0.79), NICE 86.7% (95% CI, 0.83-0.90), and NOC 90.5% (95% CI, 0.87-0.94). The odds ratio of the guidelines for predicting positive head CT findings were also reported.

DISCUSSION

Some 10%-35% of CTs obtained in the ED for MTBI were not recommended according to the guidelines. Successful implementation of existing guidelines could decrease CT use in MTBI by up to 35%, leading to a significant reduction in radiation-induced cancers and health care costs.

A case of traumatic hematoma in the basal ganglia that showed deterioration after arrival at the hospital

A case of traumatic hematoma in the basal ganglia that showed deterioration after arrival at the hospital was reported. A 65-year-old man crashed into the wall while riding a motorcycle. His Glasgow coma scale was E3V4M6 and showed retrograde amnesia and slight right motor weakness. Because head CT in the secondary trauma survey showed subarachnoid hemorrhage in the right Sylvian fissure and multiple gliding contusions in the left frontal and parietal lobe, he was entered into the intensive care unit for diagnosis of diffuse brain injury. He showed complete muscle weakness of left upper and lower limbs 5 h after the accident. Head CT newly showed hematoma, 2 cm in diameter, in the right basal ganglia. The patient vomited following the CT scan, and so his consciousness suddenly deteriorated into a stupor. We performed head CT again. The hematoma had enlarged to 5 cm at the same lesion and partially expanded into midbrain. The patient died on the 13th day of trauma. Based on retrospective interpretation, we conclude that clinical examinations, follow-up CT scans and blood examinations should be performed frequently as part of ICU management for all TBI patients in the early phase after trauma.

The Westmead head injury project: Outcome prediction in acute subdural haematoma

A prospective two year study of a consecutive sample of patients with an acute subdural haematoma who were admitted to Westmead Hospital, New South Wales, Australia was undertaken. There were 103 patients with an acute subdural haematoma admitted in the period. Twenty-four of these scored 9 or greater on the Glasgow Coma Scale (GCS) and of these all made a functional recovery, i.e. Glasgow Outcome Scale (GOS 1 or 2). The remaining 79 patients scored 8 or less on admission and of these 30% made a functional recovery. Of the 70% remaining, 4% were moderately or severely disabled (GOS 3 or 4) while 66% died (GOS 5). Age, hypoxia, hypotension, response to intracranial pressure control and two CT scan features, midline shift as measured from the septum pellucidum and cerebral oedema, were all significant in predicting outcome. Time from injury to treatment, initial pupil response, lucid interval and compression of brainstem cisterns on CT scans statistically failed to predict outcome. The data were analysed using logistic regression which showed age and midline shift to predict death or disability with an accuracy of 80% at twelve months after the injury (sensitivity 58%, specificity 89%).

The prognostic significance of traumatic brainstem injury detected on T2-weighted MRI

Object

Magnetic resonance imaging is frequently used to evaluate patients with traumatic brain injury in the acute and subacute setting, and it can detect injuries to the brainstem, which are often associated with poor outcomes. This study was undertaken to determine which MRI and clinical factors provide prognostic information in patients with traumatic brainstem injuries.

Methods

The authors performed a retrospective analysis of cases involving patients admitted to a Level I trauma center who were identified in a prospective database as having suffered traumatic brainstem injury identified on MRI. Patient outcomes were dichotomized to dead/vegetative versus functional groups. Standard demographic data, admission Glasgow Coma Scale (GCS) scores, results of the motor component of the GCS examination at admission and 24 hours later, CT scan findings, and peak intracranial pressure were collected from medical records. Volumetric analysis of each patient's injuries was performed with T2-weighted and gradient echo sequences. The T2-weighted MRI sequence for each patient was reviewed to determine the anatomical location of injury within the brainstem and whether the injury crossed the midline.

Results

Thirty-six patients who met the study inclusion criteria were identified. At 6-month follow-up, 53% of these patients had poor outcomes and 47% had recovered. Patients with injuries to the medulla or deep bilateral injuries to the pons did not recover. The T2 volumes were found superior to gradient echo sequences in regard to predicting survival (ROC/AUC 0.67, p = 0.07 vs 0.60, p = 0.29, respectively), but neither reached statistical significance. The timing of MR image acquisition did not influence the findings. The time from admission to MRI did not differ significantly between the recovered group and the poor-outcome group (p = 0.52, Mann-Whitney test), and lesion size as measured by T2 volume did not vary with time to scan (R2 = 0.03, p = 0.3, linear regression). Performing a stepwise logistic regression with all the variables yielded the following factors related to recovery: crossing midline, p = 0.0156, OR 0.075; and 24-hour GCS motor score, p = 0.0045, OR = 2.25, c-statistic 0.913. Further examination of these 2 factors disclosed the following: none of 15 patients with midline-crossing lesions and a 24-hour GCS motor score of 4 or less recovered; conversely, 12 of 13 patients with lesions that did not cross midline recovered, regardless of GCS motor score.

Conclusions

Bilateral injury to the pons and medulla as detected on T2-weighted MRI sequences was associated with poor outcome in patients with brainstem injuries; T2 volumes were found superior to gradient echo sequences in regard to predicting survival, but neither reached statistical significance. When MRI findings were coupled with clinical examination findings, a strong correlation existed between poor outcome and the combination of bilateral brainstem injury and a motor GCS score of 4 or less 24 hours after admission.

[Non-invasive evaluation of intracranial pressure: how and for whom?]

The invasive monitoring of intracranial pressure is useful in circumstances associated with high-risk of raised intracranial pressure. However the placement of intracranial probe is not always possible and non-invasive assessment of intracranial pressure may be useful, particularly in case of emergencies. Transcranial Doppler measurements allow the estimation of perfusion pressure with the pulsatility index. Recently, new ultrasonographic methods of cerebral monitoring have been developed: the diameter of the optic nerve sheath diameter, a surrogate marker of raised intracranial pressure and the estimation of median shift line deviation.

Traumatic brain injuries caused by traffic accidents in five European countries: outcome and public health consequences

BACKGROUND

Road traffic accidents (RTAs) have been identified by public health organizations as being of major global concern. Traumatic brain injuries (TBIs) are among the most severe injuries and are in a large part caused by RTA. The objective of this article is to analyse the severity and outcome of TBI caused by RTA in different types of road users in five European countries.

METHODS

The demographic, severity and outcome measures of 683 individuals with RTA-related TBI from Austria, Slovakia, Bosnia, Croatia and Macedonia were analysed. Five types of road users (car drivers, car passengers, motorcyclists, bicyclists and pedestrians) were compared using univariate and multivariate statistical methods. Short-term outcome [intensive care unit (ICU) survival] and last available long-term outcome of patients were analysed.

RESULTS

In our data set, 44% of TBI were traffic related. The median age of patients was 32.5 years, being the lowest (25 years) in car passengers. The most severe and extensive injuries were reported in pedestrians. Pedestrians had the lowest rate of ICU survival (60%) and favourable long-term outcome (46%). Drivers had the highest ICU survival (73%) and car passengers had the best long-term outcome (59% favourable). No differences in the outcome were found between countries with different economy levels.

CONCLUSION

TBI are significantly associated with RTA and thus, tackling them together could be more effective. The population at highest risk of RTA-related TBI are young males (in our sample median age: 32.5 years). Pedestrians have the most severe TBI with the worst outcome. Both groups should be a priority for public health action.

TRACING THE DEFORMED MIDLINE ON BRAIN CT

Midline shift (MLS) is the most important quantitative feature clinicians use to evaluate the severity of brain compression by various pathologies. We proposed a model of the deformed midline according to the biomechanical properties of different types of intracranial tissue. The model comprised three segments. The upper and lower straight segments represented parts of the tough meninges separating two hemispheres, and the central curved segment, formed by a quadratic Bezier curve, represented the intervening soft brain tissue. For each point of the model, the intensity difference was calculated over 48 adjacent point pairs at each side. The deformed midline was considered ideal as summed square of the difference across all midline points approaches global minimum, simulating maximal bilateral symmetry. Genetic algorithm was applied to optimize the values of the three control points of the Bezier curve. Our system was tested on images containing various pathologies from 81 consecutive patients treated in a single institute over one-year period. The deformed midlines itself as well as the amount of midline shift were evaluated by human experts, with satisfactory results.

Transcranial Doppler to screen on admission patients with mild to moderate traumatic brain injury

BACKGROUND

Detecting patients at risk for secondary neurological deterioration (SND) after mild to moderate traumatic brain injury is challenging.

OBJECTIVE

To assess the diagnostic accuracy of transcranial Doppler (TCD) on admission in screening these patients.

METHODS

This prospective, observational cohort study enrolled 98 traumatic brain injury patients with an initial Glasgow Coma Scale score of 9 to 15 whose initial computed tomography (CT) scan showed either absent or mild lesions according to the Trauma Coma Data Bank (TCDB) classification, ie, TCDB I and TCDB II, respectively. TCD measurements of the 2 middle cerebral arteries were obtained on admission under stable conditions in all patients. Neurological outcome was reassessed on day 7.

RESULTS

Of the 98 patients, 21 showed SND, ie, a decrease of ≥ 2 points from the initial Glasgow Coma Scale or requiring any treatment for neurological deterioration. Diastolic cerebral blood flow velocities and pulsatility index measurements were different between patients with SND and patients with no SND. Using receiver-operating characteristic analysis, we found the best threshold limits to be 25 cm/s (sensitivity, 92%; specificity, 76%; area under curve, 0.93) for diastolic cerebral blood flow velocity and 1.25 (sensitivity, 90%; specificity, 91%; area under curve, 0.95) for pulsatility index. According to a recursive-partitioning analysis, TCDB classification and TCD measurements were the most discriminative among variables to detect patients at risk for SND.

CONCLUSION

In patients with no severe brain lesions on CT after mild to moderate traumatic brain injury, TCD on admission, in complement with brain CT scan, could accurately screen patients at risk for SND.

Outcome analysis and outcome predictors of traumatic head injury in childhood: Analysis of 454 observations

Aim:

To determine factors associated with poor outcome in children suffering traumatic head injury (HI).

Materials and Methods:

A retrospective study over an 8-year period including 454 children with traumatic HI admitted in the Intensive Care Unit of a university hospital (Sfax-Tunisia). Basic demographic, clinical, biological and radiological data were recorded on admission and during the ICU stay. Prognosis was defined according Glasgow outcome scale (GOS) performed after hospital discharge by ICU and pediatric physicians.

Results:

There were 313 male (68.9%) and 141 female patients. Mean age (±SD) was 7.2±3.8 years, the main cause of trauma was traffic accidents (69.4%). Mean Glasgow coma scale (GCS) score was 8±3, mean injury severity score (ISS) was 26.4±8.6, mean pediatric trauma score (PTS) was 4±2 and mean pediatric risk of mortality (PRISM) was 11.1±8. The GOS performed within a mean delay of 7 months after hospital discharge was as follow: 82 deaths (18.3%), 5 vegetative states (1.1%), 15 severe disabilities (3.3%), 71 moderate disabilities (15.6%) and 281 good recoveries (61.9%). Multivariate analysis showed that factors associated with poor outcome (death, vegetative state or severe disability) were: PRISM ≥24 (P=0.03; OR: 5.75); GCS ≤8 (P=0.04; OR:2.42); Cerebral edema (P=0.03; OR:2.23); lesion type VI according to Traumatic Coma Data Bank Classification (P=0.002; OR:55.95); Hypoxemia (P=0.02; OR:2.97) and sodium level >145 mmol/l (P=0.04; OR: 4.41).

Conclusions:

A significant proportion of children admitted with HI were found to have moderate disability at follow-up. We think that improving prehospital care, establishing trauma centers and making efforts to prevent motor vehicle crashes should improve the prognosis of HI in children.