Traumatic Epidural and Subdural Hematoma: Epidemiology, Outcome, and Dating

Incidence and mortality related risk factors in patients with severe traumatic brain injury: A meta‑analysis

The present study aimed to clarify the onset of traumatic brain injury (TBI) and identify mortality-related risk factors in patients with severe TBI, to enable the early identification of high-risk individuals and timely implementation of prevention and treatment strategies to minimize mortality rates. Comprehensive database searches were conducted across Web of Science, PubMed, CINAHL and EMBASE, covering publications from database inception until October 17, 2023. Search terms in English included 'head trauma', 'brain trauma', 'mortality', 'death' and 'risk factor'. In total, two independent researchers screened and extracted the data on mortality onset and associated risk factors in patients with severe TBI. Meta-analysis was performed using R 4.2.2. A total of 33 cohort studies, including 71,718 patients with severe TBI, were selected for meta-analysis. The data indicated an overall mortality rate of 27.8% (95%CI: 22.5-33.2%) from database inception until October 17, 2023. Subgroup analysis revealed a mortality rate of 25.2% (95%CI: 20.2-30.1%) in developed countries, compared with 38.0% (95%CI: 21.4-54.7%) in developing countries. Additionally, the mean age of deceased patients was significantly higher compared with that of survivors (41.53±16.47). Key risk factors found to be associated with mortality included anemia [relative risk (RR), 1.42; 95%CI, 1.04-1.93], diabetes mellitus (RR, 1.40; 95%CI, 1.00-1.96), coagulopathy (RR, 4.31; 95%CI, 2.31-8.05), shock (RR, 3.41; 95%CI, 2.31-5.04) and systolic blood pressure≤90 mmHg (RR, 2.32; 95%CI, 1.65-3.27). Furthermore, pre-hospital intubation (RR, 1.48; 95%CI, 1.13-1.92),hypotension (RR, 2.04; 95%CI: 1.58, 2.63), hypoxemia (RR, 1.42; 95%CI: 1.13, 1.79), subdural hemorrhage (RR, 1.99; 95%CI: 1.50, 2.62), subarachnoid hemorrhage (RR, 1.64; 95%CI: 1.09, 2.47) and subdural hematoma (SDH; RR, 1.50; 95%CI: 1.04, 2.17). was identified to be a significant risk factor during hospitalization treatment. These results suggest that various factors, such as age, anemia, diabetes, shock, hypotension, hypoxemia, trauma scores and brain injury types, can all contribute to mortality risk in patients with severe TBI. Addressing these risk factors will likely be important for reducing mortality in this patient population.

The endovascular treatment strategies of cerebrovascular injuries in traumatic brain injury

Vasculature injury occurs rarely in traumatic brain injury but increases lifetime risk of ischemic or hemorrhage stroke. The diverse and nonspecific clinical manifestations make the diagnosis and treatment of these injuries highly challenging. With advancements in device design, endovascular treatments have become widely adopted, playing an increasingly vital role in the management of vascular diseases. The purpose of this review is to introduce and summarize endovascular treatments of traumatic cerebrovascular injury and other related pathological states after traumatic brain injury. Given the innovations of neuroendovascular devices and improvements in the techniques over the past decade, this review will outline several recent advancements in endovascular treatment strategies for cerebrovascular pathologies. Popularizing more treatment options to clinicians will benefit in dealing with a variety of clinical scenarios and reduce the overall morbidity of traumatic cerebrovascular injury.

Biomechanical perspectives on traumatic brain injury in the elderly: a comprehensive review

Traumatic brain injuries (TBIs) pose a significant health concern among the elderly population, influenced by age-related physiological changes and the prevalence of neurodegenerative diseases. Understanding the biomechanical dimensions of TBIs in this demographic is vital for developing effective preventive strategies and optimizing clinical management. This comprehensive review explores the intricate biomechanics of TBIs in the elderly, integrating medical and aging studies, experimental biomechanics of head tissues, and numerical simulations. Research reveals that global brain atrophy in normal aging occurs at annual rates of -0.2% to -0.5%. In contrast, neurodegenerative diseases such as Alzheimer's, Parkinson's, and multiple sclerosis are associated with significantly higher rates of brain atrophy. These variations in atrophy rates underscore the importance of considering differing brain atrophy patterns when evaluating TBIs among the elderly. Experimental studies further demonstrate that age-related changes in the mechanical properties of critical head tissues increase vulnerability to head injuries. Numerical simulations provide insights into the biomechanical response of the aging brain to traumatic events, aiding in injury prediction and preventive strategy development tailored to the elderly. Biomechanical analysis is essential for understanding injury mechanisms and forms the basis for developing effective preventive strategies. By incorporating local atrophy and age-specific impact characteristics into biomechanical models, researchers can create targeted interventions to reduce the risk of head injuries in vulnerable populations. Future research should focus on refining these models and integrating clinical data to better predict outcomes and enhance preventive care. Advancements in this field promise to improve health outcomes and reduce injury risks for the aging population.

Assessing the Impact of Pre-surgical Delay on Extradural Hematoma Outcomes

BACKGROUND

Extradural hematoma (EDH) is a life-threatening neurosurgical emergency, with timely surgical intervention critical to preventing neurological deterioration and improving patient outcomes. Delays in surgical treatment are a persistent concern, yet the specific impact of pre-surgical delays on clinical outcomes in EDH patients remains underexplored.

OBJECTIVE

This study aimed to evaluate the impact of pre-surgical delay duration on clinical outcomes in patients with EDH, specifically examining survival rates, neurological status, and recovery outcomes.

METHODOLOGY

A retrospective observational study was conducted over a two-year period (January 2022 to December 2023). Patients aged 18 years and above, diagnosed with EDH and undergoing surgical intervention, were included. Data on pre-surgical delays, demographics, comorbidities, and clinical outcomes were collected from medical records. Statistical analyses included t-tests and multivariate regression to identify predictors of adverse outcomes.

RESULTS

A total of 178 patients were analyzed. The mean pre-surgical delay was significantly longer in deceased patients (16.42 ± 6.24 hours) compared to survivors (7.92 ± 3.81 hours) (p < 0.001). Shorter pre-surgical delays (6.31 ± 2.52 hours) were associated with higher rates of full recovery compared to longer delays (12.18 ± 4.29 hours) (p < 0.001). Multivariate analysis identified pre-surgical delay, age, hypertension, and diabetes as significant predictors of adverse outcomes.

CONCLUSION

Pre-surgical delays significantly impact survival rates and recovery outcomes. Addressing logistical issues, resource constraints, and comorbid conditions is essential to minimize delays and improve patient prognosis.

Surgical Efficacy Analysis of Traumatic Posterior Fossa Epidural Hematoma in Children

OBJECTIVE

To investigate the treatment effect and prognosis of posterior fossa epidural hematoma in children by different surgical methods.

METHODS

The clinical data of 41 children with traumatic posterior fossa epidural hematoma treated by surgery in the Department of Neurosurgery from June 2015 to October 2023 were retrospectively analyzed. Among them, 32 cases underwent minimally invasive skull trepanation and drainage and 9 cases underwent craniotomy and hematoma removal. The therapeutic effects and prognosis of the two surgical methods were analyzed.

RESULTS

All the cases were successfully treated by operation. The operation time and intraoperative blood loss of the children who underwent minimally invasive skull trepanation and drainage were significantly reduced compared with those who underwent craniocerebral hematoma removal (P < 0.05), but there was no significant difference in the postoperative ventilator withdrawal time, hospitalization days, and postoperative complications between the two groups (P > 0.05). After 4 months to 2 years of follow-up, all the children recovered well, and no children died or became disabled after surgery.

CONCLUSIONS

The effect of minimally invasive skull trepanation and drainage in the treatment of posterior fossa epidural hematoma in children is similar to that of craniotomy hematoma removal, but the operation is simpler, less trauma, less intraoperative bleeding, and short operation time, which is worthy of clinical application.

RADAR - Radiomics on aSDH: predicting outcome with surface area

BACKGROUND

Acute subdural hematoma is a critical condition, leading to significant morbidity and mortality. Despite advancements in surgical techniques, a portion of patients only show limited clinical improvement post-evacuation. Surgical intervention decisions are critically important, as they can either improve or worsen a patient's condition. Radiomics offers significant potential by extracting complex patterns from digital medical images and transforming them into high-dimensional data that reflect the underlying pathophysiology. By integrating Radiomics with individual patient characteristics, we can develop decision support models. This study aims to analyze radiomic parameters of aSDH to determine whether they support the decision to proceed with urgent surgery or opt for a conservative approach. We hypothesized that surface area could be a significant predictor of neurological outcome such as maintaining independent mobility (mRS ≥ 3) and survival rates.

METHODS

This retrospective study involved radiomic analysis according to neurological outcome and survival. Radiomic parameters were measured using 3D Slicer software. Statistical analyses explored correlations, employing AUC-analysis and Kaplan-Meier survival.

RESULTS

Our findings revealed significant correlations between hematoma and surface area with poorer neurological prognosis. Further subgroup analysis showed surface area as a significant predictor for poorer outcomes in patients undergoing craniotomy (p = 0.006 in univariant- and p = 0.020 in multivariant analysis). In the total cohort, among conservatively managed and craniotomy subgroups, survival analysis highlighted an advantageous survival for patients exhibiting smaller surface areas (< 339.50 cm2).

CONCLUSIONS

Especially in craniotomy patients, surface area emerged as a possible predictor for neurological outcome and survival.

Neuroprotective effects of nutraceuticals and natural products in traumatic brain injury

Traumatic Brain Injury (TBI) is a global healthcare concern with considerable mortality and morbidity. Early diagnosis and timely treatment are critical for optimal clinical prognosis in TBI patients. Injury to the brain tissue following TBI is categorized into primary and secondary injury events, with the former being acute, while the latter evolves over a long period. Although surgical intervention is effective to treat primary injury, secondary injury events that could contribute to long term neurological deterioration, cognitive impairment and neurodegeneration do not have appropriate pharmacotherapy. To address this lacuna, studies based on modern medicine to explore novel drugs in TBI have met with limited success. This has led to focussed efforts to assess natural products capable of targeting multiple pathways in TBI. Complex natural mixtures and isolated phytochemicals capable of targeting redox mechanisms, neuroinflammation, mitochondrial dysfunction, cell death pathways and other specific targets etc. have been characterized. However, the field has met with certain limitations and challenges with inadequate clinical studies and trials being the most important concern. The current review provides an overview of the dietary factors, nutraceuticals, natural extracts, and phytochemicals that could be potentially applied in neuroprotection, TBI therapy and long-term management of cognitive symptoms and other neurological deficits.

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

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

Pre-admission opioid use disorder as a new predictor of in-hospital mortality and six-month outcomes in traumatic brain injury patients: a retrospective longitudinal cohort study

BACKGROUND

The present study aimed to investigate the effect of pre-admission Opioid Use Disorder (OUD) on in-hospital mortality and 6-month follow-up TBI outcomes.

DESIGN

This study included 2804 patients with TBI admitted to the Intensive Care Unit of Emtiaz (Rajaee) Hospital, a referral trauma center in Shiraz, Iran. Finally, 1087 eligible participants were selected from included patients. Then, 872 discharged patients were followed for six months. Subsequently, unfavorable neurological outcomes (Glasgow Outcome Scale-Extended ≤ 4) and the mortality rate were compared among the patients with and without OUD.

RESULTS

The mean age of the patients was 38.0 ± 18.9 years old (84.7% men). About 9.2% of patients had OUD. Opioid users had a slightly lower risk of in-hospital mortality (OR = 0.62, 95% CI = [0.328, 1.183], P-value = 0.148). In contrast, 6-month follow-up mortality significantly increased in the survived patients with a history of pre-admission OUD (OR = 2.49, 95%CI= [1.29, 2.80], P-value = 0.007). Moreover, 6-month unfavorable outcomes were raised in OUD, though it was not significant (OR = 1.59, 95%CI= [0.89, 2.84], P-value = 0.121).

CONCLUSIONS

Our results revealed that patients with OUD are at increased risk of 6-month follow-up complications and also death following moderate to severe TBI. Although OUD decreased in-hospital mortality, 6-month follow-up indicated that mortality and unfavorable outcomes were increased in the OUD group. Based on the existing evidence, this effect is probably not only due to the destructive impact of pre-admission OUD on brain physiology. However, it may also be due to an increase in opioid consumption to alleviate pain and withdrawal symptoms after hospital discharge.

Hydrogel in the Treatment of Traumatic Brain Injury

The high prevalence of traumatic brain injury (TBI) poses an important global public health challenge. Current treatment modalities for TBI primarily involve pharmaceutical interventions and surgical procedures; however, the efficacy of these approaches remains limited. In the field of regenerative medicine, hydrogels have garnered significant attention and research efforts. This review provides an overview of the existing landscape and pathological manifestations of TBI, with a specific emphasis on delineating the therapeutic potential of hydrogels incorporated with various bioactive agents for TBI management. Particularly, the review delves into the utilization and efficacy of hydrogels based on extracellular matrix (ECM), stem cell-loaded, drug-loaded, self-assembled peptide structures or conductive in the context of TBI treatment. These applications are shown to yield favorable outcomes such as tissue damage mitigation, anti-inflammatory effects, attenuation of oxidative stress, anti-apoptotic properties, promotion of neurogenesis, and facilitation of angiogenesis. Lastly, a comprehensive analysis of the merits and constraints associated with hydrogel utilization in TBI treatment is presented, aiming to steer and advance future research endeavors in this domain.

Neurobiology and medico-legal aspects of suicides among older adults: a narrative review

The task of preventing suicide in older adults is an important social burden as older adults aged above 65 are exposed to singular psychological aspects that increase suicide risks. Moreover, when an older adult corpse is found, the medico-legal inspection represents a fundamental tool to identify the exact cause of death, classifying or excluding it as suicide. In this scenario, this review aims to explore the neurobiological factors that could be related to suicidal behavior in older adults. A further goal of this review is the exploration of the medico-legal aspects surrounding older adult suicides, clarifying the importance of forensic investigation. Particularly, this review examines issues such as neurotransmitter imbalances, cognitive impairment, neuroinflammation, psychosocial factors related to geriatric suicide, and neurodegenerative diseases. Additionally, medico-legal aspects such as policy considerations, legal frameworks, mental health assessments, ethical implications and forensic investigation were explored. Considering the importance of this phenomenon, especially in western countries, a need has emerged for focused screening tools on suicidal behavior among older adults, in order to contain it. Therefore, this review makes an exhaustive appraisal of the literature giving insights into the delicate interplay between neurobiology as well as mental health in relation to older adult suicide within a medico-legal context. The comprehension of different aspects about this complex phenomenon is fundamental to propose new and more effective interventions, supporting tailored initiatives such as family support and improving healthcare, specifically towards vulnerable ageing societies to reduce older adult suicide risks.

The role of coagulopathy and subdural hematoma thickness at admission in predicting the prognoses of patients with severe traumatic brain injury: a multicenter retrospective cohort study from China

BACKGROUND

Traumatic brain injury (TBI) is one of the diseases with high disability and mortality worldwide. Recent studies have shown that TBI-related factors may change the complex balance between bleeding and thrombosis, leading to coagulation disorders. The aim of this retrospective study was to investigate the prediction of coagulopathy and subdural hematoma thickness at admission using the Glasgow Outcome Scale (GOS) in patients with severe TBI at 6 months after discharge.

METHODS

In this retrospective cohort study, a total of 1006 patients with severe TBI in large medical centers in three different provinces of China from June 2015 to June 2021 were enrolled after the exclusion criteria, and 800 patients who met the enrollment criteria were included. A receiver operating characteristic (ROC) curve was used to determine the best cut-off values of platelet (PLT), international normalized ratio (INR), activated partial thromboplastin time (APTT), and subdural hematoma (SDH) thickness. The ROC curve, nomogram, calibration curve, and the decision curve were used to evaluate the predictive effect of the coagulopathy and Coagulopathy-SDH(X1) models on the prognoses of patients with severe TBI, and the importance of predictive indicators was ranked by machine learning.

RESULTS

Among the patients with severe TBI on admission, 576/800 (72%) had coagulopathy, 494/800 (61%) had SDH thickness ≥14.05 mm, and 385/800 (48%) had coagulopathy combined with SDH thickness ≥14.05 mm. Multivariate logistic regression analyses showed that age, pupil, brain herniation, WBC, CRP, SDH, coagulopathy, and X1 were independent prognostic factors for GOS after severe TBI. Compared with other single indicators, X1 as a predictor of the prognosis of severe TBI was more accurate. The GOS of patients with coagulopathy and thick SDH (X1, 1 point) at 6 months after discharge was significantly worse than that of patients with coagulopathy and thin SDH (X1, 2 points), patients without coagulopathy and thick SDH (X1, 3 point), and patients without coagulopathy and thin SDH (X1, 4 points). In the training group, the C-index based on the coagulopathy nomogram was 0.900. The C-index of the X1-based nomogram was 0.912. In the validation group, the C-index based on the coagulopathy nomogram was 0.858. The C-index of the X1-based nomogram was 0.877. Decision curve analysis also confirmed that the X1-based model had a higher clinical net benefit of GOS at 6 months after discharge than the coagulopathy-based model in most cases, both in the training and validation groups. In addition, compared with the calibration curve based on the coagulopathy model, the prediction of the X1 model-based calibration curve for the probability of GOS at 6 months after discharge showed better agreement with actual observations. Machine learning compared the importance of each independent influencing factor in the evaluation of GOS prediction after TBI, with results showing that the importance of X1 was better than that of coagulopathy alone.

CONCLUSION

Coagulopathy combined with SDH thickness could be used as a new, accurate, and objective clinical predictor, and X1, based on combining coagulopathy with SDH thickness could be used to improve the accuracy of GOS prediction in patients with TBI, 6 months after discharge.

A Case of Spontaneous Atraumatic Subdural Hematoma Without Known Precipitating Factors

Subdural hematoma (SDH) is a disease commonly seen in both the emergency department and the intensive care unit. Here, we present a case of a woman who developed acute SDH, without any precipitating trauma nor predisposing risk factors. She was managed with hemicraniectomy and SDH evacuation, with subsequent cranioplasty. Routine surveillance imaging found a subsequent, small, and again idiopathic SDH. Comprehensive hematologic workup demonstrated no evidence of coagulopathy. To our knowledge, there are minimal prior case reports published in the literature regarding idiopathic, unprovoked SDH.

Anti-HMGB1 mAb Therapy Reduces Epidural Hematoma Injury

Epidural and subdural hematomas are commonly associated with traumatic brain injury. While surgical removal is the primary intervention for these hematomas, it is also critical to prevent and reduce complications such as post-traumatic epilepsy, which may result from inflammatory responses in the injured brain areas. In the present study, we observed that high mobility group box-1 (HMGB1) decreased in the injured brain area beneath the epidural hematoma (EDH) in rats, concurrent with elevated plasma levels of HMGB1. Anti-HMGB1 monoclonal antibody therapy strongly inhibited both HMGB1 release and the subsequent increase in plasma levels. Moreover, this treatment suppressed the up-regulation of inflammatory cytokines and related molecules such as interleukin-1-beta (IL-1β), tumor necrosis factor-alpha (TNF-α), and inducible nitric oxide synthase (iNOS) in the injured areas. Our in vitro experiments using SH-SY5Y demonstrated that hematoma components-thrombin, heme, and ferrous ion- prompted HMGB1 translocation from the nuclei to the cytoplasm, a process inhibited by the addition of the anti-HMGB1 mAb. These findings suggest that anti-HMGB1 mAb treatment not only inhibits HMGB1 translocation but also curtails inflammation in injured areas, thereby protecting the neural tissue. Thus, anti-HMGB1 mAb therapy could serve as a complementary therapy for an EDH before/after surgery.

Metabolome-Wide Mendelian Randomization Assessing the Causal Role of Serum and Cerebrospinal Metabolites in Traumatic Brain Injury

Previous studies have identified metabolites as biomarkers or potential therapeutic targets for traumatic brain injury (TBI). However, the causal association between them remains unknown. Therefore, we investigated the causal effect of serum metabolites and cerebrospinal fluid (CSF) metabolites on TBI susceptibility through Mendelian randomization (MR). Genetic variants related to metabolites and TBI were extracted from a corresponding genome-wide association study (GWAS). Causal effects were estimated through the inverse variance weighted approach, supplemented by a weighted median, weight mode, and the MR-Egger test. In addition, sensitivity analyses were further performed to evaluate the stability of the MR results, including the MR-Egger intercept, leave-one-out analysis, Cochrane's Q-test, and the MR-PRESSO global test. Metabolic pathway analysis was applied to uncover the underlying pathways of the significant metabolites in TBI. In blood metabolites, substances such as 4-acetaminophen sulfate and kynurenine showed positive links, whereas beta-hydroxyisovalerate and creatinine exhibited negative correlations. CSF metabolites such as N-formylanthranilic acid were positively related, while kynurenate showed negative associations. The metabolic pathway analysis highlighted the potential biological pathways involved in TBI. Of these 16 serum metabolites, 11 CSF metabolites and metabolic pathways may serve as useful circulating biomarkers in clinical screening and prevention, and may be candidate molecules for the exploration of mechanisms and drug targets.

Clinico-radiological correlation with outcome in acute epidural haematoma: a tertiary centre experience from Nepal

Background

Epidural haematoma (EDH) accounts for up to 15% of severe traumatic brain injury (TBI) cases and remains the most common cause of mortality and disability. Several clinical and radiological factors affect patient outcomes. This study aims to correlate patients' clinical and radiological profiles with acute EDH outcomes.

Methods

A retrospective, single-centred, consecutive case series was conducted on the patients diagnosed with an acute EDH admitted to Tribhuvan University Teaching Hospital (TUTH) between May 2019 and April 2023. The modified Rankin scale (mRS) was used to assess the outcome. Univariate analysis and Kruskal-Wallis H test with Dunn-Bonferroni post-hoc test was conducted.

Results

There were 107 patients diagnosed with EDH, of which 52.3% were less than 20 years old with male preponderance. Falls were the most common mechanism of injury (64.5%), and most cases were referred to, not brought directly. The majority had a GCS score greater than or equal to 13 (85%) at presentation, and only 5.5% had a GCS score less than or equal to 8. According to the mRS, most patients had favourable outcomes, with 88.7% having no significant disability and 11.3% having a slight disability.

Conclusion

This case series is the largest and most recent report from Nepal and demonstrated that GCS, pupillary response, skull fracture, neurological symptoms, pre-hospital and intra-hospital delay, and management modalities are critical factors in determining the total hospital and ICU stay but did not have an impact on the mRS scores.

Prediction of therapeutic intensity level from automatic multiclass segmentation of traumatic brain injury lesions on CT-scans

The prediction of the therapeutic intensity level (TIL) for severe traumatic brain injury (TBI) patients at the early phase of intensive care unit (ICU) remains challenging. Computed tomography images are still manually quantified and then underexploited. In this study, we develop an artificial intelligence-based tool to segment brain lesions on admission CT-scan and predict TIL within the first week in the ICU. A cohort of 29 head injured patients (87 CT-scans; Dataset1) was used to localize (using a structural atlas), segment (manually or automatically with or without transfer learning) 4 or 7 types of lesions and use these metrics to train classifiers, evaluated with AUC on a nested cross-validation, to predict requirements for TIL sum of 11 points or more during the 8 first days in ICU. The validation of the performances of both segmentation and classification tasks was done with Dice and accuracy scores on a sub-dataset of Dataset1 (internal validation) and an external dataset of 12 TBI patients (12 CT-scans; Dataset2). Automatic 4-class segmentation (without transfer learning) was not able to correctly predict the apparition of a day of extreme TIL (AUC = 60 ± 23%). In contrast, manual quantification of volumes of 7 lesions and their spatial location provided a significantly better prediction power (AUC = 89 ± 17%). Transfer learning significantly improved the automatic 4-class segmentation (DICE scores 0.63 vs 0.34) and trained more efficiently a 7-class convolutional neural network (DICE = 0.64). Both validations showed that segmentations based on transfer learning were able to predict extreme TIL with better or equivalent accuracy (83%) as those made with manual segmentations. Our automatic characterization (volume, type and spatial location) of initial brain lesions observed on CT-scan, publicly available on a dedicated computing platform, could predict requirements for high TIL during the first 8 days after severe TBI. Transfer learning strategies may improve the accuracy of CNN-based segmentation models.Trial registrations Radiomic-TBI cohort; NCT04058379, first posted: 15 august 2019; Radioxy-TC cohort; Health Data Hub index F20220207212747, first posted: 7 February 2022.

Cellular and Molecular Pathophysiology of Traumatic Brain Injury: What Have We Learned So Far?

Traumatic brain injury (TBI) is one of the leading causes of long-lasting morbidity and mortality worldwide, being a devastating condition related to the impairment of the nervous system after an external traumatic event resulting in transitory or permanent functional disability, with a significant burden to the healthcare system. Harmful events underlying TBI can be classified into two sequential stages, primary and secondary, which are both associated with breakdown of the tissue homeostasis due to impairment of the blood-brain barrier, osmotic imbalance, inflammatory processes, oxidative stress, excitotoxicity, and apoptotic cell death, ultimately resulting in a loss of tissue functionality. The present study provides an updated review concerning the roles of brain edema, inflammation, excitotoxicity, and oxidative stress on brain changes resulting from a TBI. The proper characterization of the phenomena resulting from TBI can contribute to the improvement of care, rehabilitation and quality of life of the affected people.

The importance of additional intracranial injuries in epidural hematomas: detailed clinical analysis, long-term outcome, and literature review in surgically managed epidural hematomas

Objective

Epidural hematomas (EDH) occur in up to 8.2% of all traumatic brain injury patients, with more than half needing surgical treatment. In most patients suffering from this perilous disease, good recovery with an excellent clinical course is possible. However, the clinical course is mainly dependent on the presence of additional intracerebral injuries. Few studies comparing isolated and combined EDH in detail exist.

Methods

We performed a retrospective single-center study from April 2002 to December 2014. The mean follow-up time was more than 6 years. In addition to analyzing diverse clinicoradiological data, we performed a systematic literature review dealing with a detailed comparison of patients with (combined) and without (isolated) additional intracerebral injuries.

Results

We included 72 patients in the study. With increasing age, combined EDH had a higher incidence than isolated EDH. The mortality rate of the patients in the cohort was 10%, of which 0% had isolated EDH and 10% had combined EDH. Good recovery was achieved in 69% of patients, of which 91% had isolated EDH and 50% had combined EDH. A subgroup analysis of the different additional intracerebral injuries in combined EDH demonstrated no significant difference in outcome. A systematic literature review only identified six studies. Patients with isolated EDH had a statistically significantly lower mortality risk [relative risk (RR): 0.22; 95% CI: 0.12-0.39] and a statistically significantly lower risk of unfavorable Glasgow outcome scale score (RR: 0.21; 95% CI: 0.14-0.31) than patients with combined EDH.

Conclusions

An excellent outcome in patients with surgically treated isolated EDH is possible. Furthermore, patients with combined EDH or isolated EDH with a low Glasgow coma scale (GCS) score may have favorable outcomes in 50% of the cases. Therefore, every possible effort for treatment should be made for this potentially lethal injury.

Comparing Predictive Utility of Head Computed Tomography Scan-Based Scoring Systems for Traumatic Brain Injury: A Retrospective Study

This study compared the predictive utility of Marshall, Rotterdam, Stockholm, Helsinki, and NeuroImaging Radiological Interpretation System (NIRIS) scorings based on early non-contrast brain computed tomography (CT) scans in patients with traumatic brain injury (TBI). The area under a receiver operating characteristic curve (AUROC) was used to determine the predictive utility of scoring systems. Subgroup analyses were performed among patients with head AIS scores > 1. A total of 996 patients were included, of whom 786 (78.9%) were males. In-hospital mortality, ICU admission, neurosurgical intervention, and prolonged total hospital length of stay (THLOS) were recorded for 27 (2.7%), 207 (20.8%), 82 (8.2%), and 205 (20.6%) patients, respectively. For predicting in-hospital mortality, all scoring systems had AUROC point estimates above 0.9 and 0.75 among all included patients and patients with head AIS > 1, respectively, without any significant differences. The Marshall and NIRIS scoring systems had higher AUROCs for predicting ICU admission and neurosurgery than the other scoring systems. For predicting THLOS ≥ seven days, although the NIRIS and Marshall scoring systems seemed to have higher AUROC point estimates when all patients were analyzed, five scoring systems performed roughly the same in the head AIS > 1 subgroup.

Bleeding-Source Exploration in Subdural Hematoma: Observational Study on the Usefulness of Postmortem Computed Tomography Angiography

In a few cases, postmortem computed tomography angiography (PMCTA) is effective in postmortem detection of cortical artery rupture causing subdural hematoma (SDH), which is difficult to detect at autopsy. Here, we explore the usefulness and limitations of PMCTA in detecting the sites of cortical arterial rupture for SDH. In 6 of 10 cases, extravascular leakage of contrast material at nine different places enabled PMCTA to identify cortical arterial rupture. PMCTA did not induce destructive arterial artifacts, which often occur during autopsy. We found that, although not in all cases, PMCTA could show the site of cortical arterial rupture causing subdural hematoma in some cases. This technique is beneficial for cases of SDH autopsy, as it can be performed nondestructively and before destructive artifacts from the autopsy occur.

Coexistence of ipsilateral acute-on-chronic subdural hematoma and acute extradural hematoma: A case report

Chronic subdural hematomas are typically observed in elderly patients receiving antithrombotic and/or anticoagulant therapy. In contrast, acute subdural and extradural hematomas are often observed in young people with traumatic brain injury. The coexistence of ipsilateral chronic subdural and extradural hematomas is rare. Depending on the Glasgow Coma Scale and neuroimaging findings, early surgical intervention is mandatory, as seen in our patient. Early surgical evacuation of a traumatic extradural and chronic subdural hematoma should be done. Also, antithrombotic drug use can lead to chronic subdural hematoma.

Evaluation of a Set of miRNAs in 26 Cases of Fatal Traumatic Brain Injuries

In forensic medicine, identifying novel biomarkers for use as diagnostic tools to ascertain causes of death is challenging because of sample degradation. To that aim, a cohort (n = 26) of fatal traumatic brain injuries (TBIs) were tested for three candidate miRNAs (namely, miR-124-3p, miR-138-5p, and miR144-3p). For each case, three FFPE specimens (coup area (CA), contrecoup area (CCA), and the corpus callosum (CC)) were investigated, whereas the FFPE brain tissues of 45 subjects (deceased due to acute cardiovascular events) were used as controls. Relative quantification via the ∆∆Ct method returned significantly higher expression levels of the three candidate miRNAs (p < 0.01) in the TBI cases. No difference was detected in the expression levels of any miRNA investigated in the study among the CA, CCA, and CC. Furthermore, the analyzed miRNAs were unrelated to the TBI samples' post-mortem intervals (PMIs). On the contrary, has-miR-124-3p ahashsa-miR-144-3p were significantly correlated (p < 0.01) with the agonal time in TBI deaths. Since the RNA was highly degraded in autoptic FFPE tissues, it was impossible to analyze the mRNA targets of the miRNAs investigated in the present study, highlighting the necessity of standardizing pre-analytical processes even for autopsy tissues.

External Validation of an Artificial Intelligence Device for Intracranial Hemorrhage Detection

BACKGROUND

Artificial intelligence applications have gained traction in the field of cerebrovascular disease by assisting in the triage, classification, and prognostication of both ischemic and hemorrhagic stroke. The Caire ICH system aims to be the first device to move into the realm of assisted diagnosis for intracranial hemorrhage (ICH) and its subtypes.

METHODS

A single-center retrospective dataset of 402 head noncontrast CT scans (NCCT) with an intracranial hemorrhage were retrospectively collected from January 2012 to July 2020; an additional 108 NCCT scans with no intracranial hemorrhage findings were also included. The presence of an ICH and its subtype were determined from the International Classification of Diseases-10 code associated with the scan and validated by an expert panel. We used the Caire ICH vR1 to analyze these scans, and we evaluated its performance in terms of accuracy, sensitivity, and specificity.

RESULTS

We found the Caire ICH system to have an accuracy of 98.05% (95% confidence interval [CI]: 96.44%-99.06%), a sensitivity of 97.52% (95% CI: 95.50%-98.81%), and a specificity of 100% (95% CI: 96.67%-100.00%) in the detection of ICH. Experts reviewed the 10 incorrectly classified scans.

CONCLUSIONS

The Caire ICH vR1 algorithm was highly accurate, sensitive, and specific in detecting the presence or absence of an ICH and its subtypes in NCCTs. This work suggests that the Caire ICH device has potential to minimize clinical errors in ICH diagnosis that could improve patient outcomes and current workflows as both a point-of-care tool for diagnostics and as a safety net for radiologists.

Burr hole as a management for extra axial hematomas in a low-resource setting

INTRODUCTION AND IMPORTANCE

In a low-resource setting, the availability of neurosurgeons and neurosurgical equipment for neurosurgery has proved to be a challenge for the management of extra-axial hematomas hence general surgeons perform burr hole surgeries for emergencies.

CASE PRESENTATION

We share our experience with three patients who presented with extra-axial hematomas and managed successfully in our institute with craniostomy as the surgical approach.

CLINICAL DISCUSSION

Traumatic brain injury is a major global health burden as it is a leading cause of death among the middle-aged population. Mortality associated with brain injury is highest in low- and middle-income countries. From our experience, we had good outcome in terms of improved Glasgow Coma Scale and overall clinical status in those who underwent burr hole surgery for extra axial hematoma.

CONCLUSION

The need for neurosurgeons in sub-Saharan Africa is high but training comes at a cost hence general surgeons can perform life-saving emergency procedures with good outcomes.

Minimally invasive puncture with twist intraosseous drill needle combined with hematoma drainage in the treatment of acute epidural hematoma in pediatric patients: A technical note

OBJECTIVE

The current neurosurgical intervention for treatment of acute epidural hematoma (AEDH) usually involves a craniotomy. Despite its effectiveness, open surgical decompression has several limitations. The twist intraosseous drill needle (TIDN) is considered a feasible alternative in adult patients with AEDH. AEDH treatment with TIDN in pediatric patients has not yet been described. The study aimed to report the efficacy and safety of minimally invasive puncture with a TIDN combined with hematoma drainage for the treatment of AEDH in pediatric patients.

METHODS

We retrospectively collected medical records of children with AEDH who underwent TIDN surgery at our institution from January 2017 to May 2021, and analyzed their clinical and imaging results. A detailed step-by-step surgical guide was provided.

RESULTS

Three pediatric patients with AEDH received TIDN treatment (including two males and one female; average age 7.66 years, range from 5 to 11 years). There were no intraoperative or postoperative complications in any case; 1 day after the operation, the AEDH was cleared in one of the three patients, and a slight hematoma remained in two patients. The remaining hematoma was evacuated after injecting urokinase into the hematoma cavity during indwelling drainage.

CONCLUSION

For pediatric patients with AEDH in a stable condition with a clear consciousness, TIDN puncture combined with hematoma drainage is safe, effective, and less invasive, and may present a viable surgical alternative option.

Novel CT-based parameters assessing relative cross-sectional area to guide surgical management and predict clinical outcomes in patients with acute subdural hematoma

INTRODUCTION

Acute subdural hematoma (aSDH) is one of the most devastating entities secondary to traumatic brain injury (TBI). Even though radiological computed tomography (CT) findings, such as hematoma thickness (HT), midline shift (MLS), and MLS/HT ratio, have an important prognostic role, they suffer from important drawbacks. We hypothesized that relative cross-sectional area (rCSA) of specific brain regions would provide valuable information about brain compression and swelling, thus being a key determining factor governing the clinical course.

METHODS

We performed an 8-year retrospective analysis of patients with moderate to severe TBI with surgically evacuated, isolated, unilateral aSDH. We investigated the influence of aSDH rCSA and ipsilateral hemisphere rCSA along the supratentorial region on the subsequent operative technique employed for aSDH evacuation and patient's clinical outcomes (early death and Glasgow Outcome Scale [GOS] at discharge and after 1-year follow-up). Different conventional radiological variables were also assessed.

RESULTS

The study included 39 patients. Lower HT, MLS, hematoma volume, and aSDH rCSA showed a significant association with decompressive craniectomy (DC) procedure. Conversely, higher ipsilateral hemisphere rCSA along the dorso-ventral axis and, specifically, ipsilateral hemisphere rCSA at the high convexity level were predictors for DC. CT segmentation analysis exhibited a modest relationship with early death, which was limited to the basal supratentorial subregion, but could not predict long-term outcome.

CONCLUSION

rCSA is an objectifiable and reliable radiologic parameter available on admission CT that might provide valuable information to optimize surgical treatment.

A bibliometric analysis on traumatic brain injury in forensic medicine of a half-century (1972-2021)

Traumatic brain injury (TBI) is among the most common injuries in forensic medicine, the identification of which is of particular importance in forensic practice. To reveal the circumstances and trends of TBI in the forensic field, we used the Web of Science (WoS) database for comprehensive retrieval. We made a metrological analysis of 1,089 papers in the past 50 years (1972-2021). The United States and Germany have the most forensic research on TBI. Diffuse axonal injury (DAI) has been the focus of attention for many years, and much effort has been devoted to its diagnosis in forensic pathology. Infants and children are the subgroups of most concern, especially in infant and child abuse cases. Research on identifying shaken baby syndrome has received increasing attention in recent years. Overall, our study provides a comprehensive list and analysis of the articles regarding TBI in legal medicine, which may shed light on recognizing the trends and research hotspots in this field.

Decompressive Craniectomy in the Management of Low Glasgow Coma Score Patients With Extradural Hematoma: A Review of Literature and Guidelines

An extradural hematoma (EDH), also known as an epidural hematoma, is a collection of blood between the inner skull table and the dura mater. It is restricted by the coronal, lambdoid, and sagittal sutures, as these are dural insertions. EDH most frequently occurs in 10- to 40-year-old patients. EDH is uncommon after age 60, as dura matter adheres firmly to the inner skull table. EDH is more common among men as compared to women. EDH most commonly occurs in the temporo-frontal regions and can also be seen in the parieto-occipital, parasagittal regions, and middle and posterior fossae. An EDH contributes approximately 2% of total head injuries and 15% of total fatal head injuries. In EDH, patients typically have a persistent, severe headache, and also, following a few hours of injury, they gradually lose consciousness. The primary bleeding vessels for EDH are the middle meningeal artery, middle meningeal vein, and torn dural venous sinuses. EDH is one of the many consequences of severe traumatic brain injuries that might lead to death. EDH is potentially a lethal condition that requires immediate intervention as, if left untreated, it can lead to growing transtentorial herniation, diminished consciousness, dilated pupils, and other neurological problems. Non-contrast computed tomography (NCCT) imaging is the gold standard of investigation for diagnosing EDH. For patients with surgical indications, early craniotomy and evacuation of acute extradural hematoma (AEDH) is the gold standard procedure and is predicted to have significant clinical results. Nevertheless, there is an ongoing debate regarding the best surgical operations for AEDH. Neurosurgeons must choose between a decompressive craniectomy (DC) or a craniotomy to manage EDH, especially in patients with low Glasgow coma scores, to have a better prognosis and clinical results. This is a consultant-based review article in which we have tried to contemplate various pieces of available literature. Here, the objective is to hypothesize DC as the primary surgical management for massive hematoma, which usually presents as a low Glasgow coma score. This is because DC was found to be beneficial in clinical practice.

Cervical spine injury: clinical and medico-legal overview

Spinal trauma is an important cause of disability worldwide. Injury to the cervical spine (CS) occurs frequently after major trauma. 5-10% of patients with blunt trauma have a cervical spine injury. The cervical spine accounts for ~ 50% of all spinal injuries. Determination of CS stability is a common challenge in the acute care setting of patients with trauma. Several issues, indeed, are of particular concern: who needs CS imaging; what imaging should be obtained; when should computed tomography (CT), magnetic resonance imaging (MRI), or flexion/extension (F/E) radiographs be obtained; and how is significant ligamentous injury excluded in the comatose patient. CT and MRI both have roles to play. This article aims to present the different imaging to frame techniques to be used with greater precision in the acute event also for the purpose of planning the next therapeutic process. An overview of the applicability of the same methods in forensic pathology is also provided highlighting possible future biomarker to ease in diagnosis of acute TBI.

Long-Term Outcomes in Severe Traumatic Brain Injury and Associated Factors: A Prospective Cohort Study

OBJECTIVE

The presence of focal lesion (FL) after a severe traumatic brain injury is an important factor in determining morbidity and mortality. Despite this relevance, few studies show the pattern of recovery of patients with severe traumatic brain injury (TBI) with FL within one year. The objective of this study was to identify the pattern of recovery, independence to perform activities of daily living (ADL), and factors associated with mortality and unfavorable outcome at six and twelve months after severe TBI with FL.

METHODOLOGY

This is a prospective cohort, with data collected at admission, hospital discharge, three, six, and twelve months after TBI.

RESULTS

The study included 131 adults with a mean age of 34.08 years. At twelve months, 39% of the participants died, 80% were functionally independent by the Glasgow Outcome Scale Extended, 79% by the Disability Rating Scale, 79% were independent for performing ADLs by the Katz Index, and 53.9% by the Lawton Scale. Report of alcohol intake, sedation time, length of stay in intensive care (ICU LOS), Glasgow Coma Scale, trauma severity indices, hyperglycemia, blood glucose, and infection were associated with death. At six and twelve months, tachypnea, age, ICU LOS, trauma severity indices, respiratory rate, multiple radiographic injuries, and cardiac rate were associated with dependence.

CONCLUSIONS

Patients have satisfactory functional recovery up to twelve months after trauma, with an accentuated improvement in the first three months. Clinical and sociodemographic variables were associated with post-trauma outcomes. Almost all victims of severe TBI with focal lesions evolved to death or independence.

Glymphatic System a Window on TBI Pathophysiology: A Systematic Review

BACKGROUND

In recent years, the attention of the scientific world has focused on a clearance system of brain waste metabolites, called the glymphatic system, based on its similarity to the lymphatic system in peripheral tissue and the relevant role of the AQP4 glial channels and described for the first time in 2012. Consequently, numerous studies focused on its role in organ damage in cases of neuropathologies, including TBI.

METHODS

To evaluate the role that the glymphatic system has in the pathogenesis of TBI, on 23 March 2022, a systematic review of the literature according to PRISMA guidelines was carried out using the SCOPUS and Medline (via PubMed) databases, resulting in 12 articles after the selection process.

DISCUSSION AND CONCLUSION

The present review demonstrated that an alteration of AQP4 is associated with the accumulation of substances S100b, GFAP, and NSE, known markers of TBI in the forensic field. In addition, the alteration of the functionality of AQP4 favors edema, which, as already described, constitutes alterations of secondary brain injuries. Moreover, specific areas of the brain were demonstrated to be prone to alterations of the glymphatic pathway, suggesting their involvement in post-TBI damage. Therefore, further studies are mandatory. In this regard, a study protocol on cadavers is also proposed, based on the analyzed evidence.

An investigation of cerebral bridging veins rupture due to head trauma

Subdural hematoma (SDH) is common abnormality that is caused by the rupture of cerebral bridge veins (BVs). It occurs in more than 30% of severe head injuries. The purpose of this research was to develop a numerical model to examine the effects of brain atrophy and age on the rupture of bridging veins in subdural hematoma. Three types of models were developed to simulate subdural hematoma, namely global solid, global FSI, and local solid models. In the next step, a head impact with the head injury criterion (HIC) value of 744 was applied as a loading condition to global models. For the global solid models, we measured the relative displacement between the skull and brain. We extracted the pressure distribution from the global FSI models. The data were used as boundary conditions on the local models to evaluate the damage to the cerebral bridge veins precisely The results showed that the relative displacement was greater in the atrophied model compared to the healthy one (2.64 and 2.20 mm, respectively). In addition, the pressure value was higher in atrophied models. In the healthy local model, the maximum strain on BVs was around 1.38, while in the atrophied model, it was 2.77. The head impact, which had a HIC value of 744, did not cause serious injury to a human with a healthy brain, but it caused severe damage to an atrophied brain. The degeneration of the brain and intracranial space changes are two important factors for the movement of the brain and its vulnerability to impact.

Emergency Craniotomy and Burr-Hole Trephination in a Low-Resource Setting: Capacity Building at a Regional Hospital in Cambodia

To evaluate the teaching effect of a trauma training program in emergency cranial neurosurgery in Cambodia on surgical outcomes for patients with traumatic brain injury (TBI). We analyzed the data of TBI patients who received emergency burr-hole trephination or craniotomy from a prospective, descriptive cohort study at the Military Region 5 Hospital between January 2015 and December 2016. TBI patients who underwent emergency cranial neurosurgery were primarily young men, with acute epidural hematoma (EDH) and acute subdural hematoma (SDH) as the most common diagnoses and with long transfer delay. The incidence of favorable outcomes three months after chronic intracranial hematoma, acute SDH, acute EDH, and acute intracerebral hematoma were 96.28%, 89.2%, 93%, and 97.1%, respectively. Severe traumatic brain injury was associated with long-term unfavorable outcomes (Glasgow Outcome Scale of 1–3) (OR = 23.9, 95% CI: 3.1–184.4). Surgical outcomes at 3 months appeared acceptable. This program in emergency cranial neurosurgery was successful in the study hospital, as evidenced by the fact that the relevant surgical capacity of the regional hospital increased from zero to an acceptable level.

Association Between Intensive Care Unit Admission Practices and Outcomes in Patients with Isolated Traumatic Subarachnoid Hemorrhage: A Nationwide Inpatient Database Analysis in Japan

BACKGROUND

Patients with traumatic brain injury associated with intracranial hemorrhage are commonly admitted to the intensive care unit (ICU); however, the need for ICU care for patients with isolated traumatic subarachnoid hemorrhage (tSAH) remains unclear. We aimed to investigate the association between the ICU admission practices and outcomes in patients with isolated tSAH.

METHODS

This observational study used a nationwide administrative database in Japan. We identified patients with isolated tSAH from the Japanese Diagnostic Procedure Combination inpatient database from July 1, 2010, to March 31, 2020. The primary outcome was in-hospital mortality, whereas the secondary outcomes were neurosurgical interventions, activities of daily living at discharge, and total hospitalization cost. We performed a risk-adjusted mixed-effect regression analysis to evaluate the association between hospital-level ICU admission rates and study outcomes. The ICU admission rates were categorized into quartiles: lowest, middle-low, middle-high, and highest. Moreover, we assessed the robustness of the results with a patient-level instrumental variable analysis.

RESULTS

Of the 61,883 patients with isolated tSAH treated at 962 hospitals, 16,898 (27.3%) patients were admitted to the ICU on the day of admission. Overall, 2465 (4.0%) patients died in the hospital, and 783 (1.3%) patients underwent neurosurgical interventions. There was no significant difference between the lowest and highest ICU admission quartile in terms of in-hospital mortality (3.7% vs. 4.3%; adjusted odds ratio 0.93; 95% confidence interval [CI] 0.78-1.10), neurosurgical interventions, and activities of daily living at discharge. However, the total hospitalization cost in the lowest ICU admission quartile was significantly lower than that in the highest quartile (US $3032 vs. $4095; adjusted difference US $560; 95% CI 33-1087). The patient-level instrumental variable analysis did not reveal a significant difference in in-hospital mortality between the patients who were admitted to the ICU and those who were not (risk difference 0.2%; 95% CI - 0.1 to 0.5).

CONCLUSIONS

There was no significant association between the ICU admission practices and outcomes in patients with isolated tSAH, whereas higher ICU admission rates were associated with significantly higher hospitalization costs. Our results provide an opportunity for improved health care allocation in the management of patients with isolated tSAH.

Ketamine in Acute Brain Injury: Current Opinion Following Cerebral Circulation and Electrical Activity

The use of ketamine in patients with TBI has often been argued due to its possible deleterious effects on cerebral circulation and perfusion. Early studies suggested that ketamine could increase intracranial pressure, decreasing cerebral perfusion pressure and thereby reducing oxygen supply to the damaged cerebral cortex. Some recent studies have refuted these conclusions relating to the role of ketamine, especially in patients with TBI, showing that ketamine should be the first-choice drug in this type of patient at induction. Our narrative review collects evidence on ketamine’s use in patients with TBI. Databases were examined for studies in which ketamine had been used in acute traumatic brain injury (TBI). The outcomes considered in this narrative review were: mortality of patients with TBI; impact on intracranial pressure and cerebral perfusion pressure; blood pressure and heart rate values; depolarization rate; and preserved neurological functions. 11 recent studies passed inclusion and exclusion criteria and were included in this review. Despite all the benefits reported in the literature, the use of ketamine in patients with brain injury still appears to be limited. A slight increase in intracranial pressure was found in only two studies, while two smaller studies showed a reduction in intracranial pressure after ketamine administration. There was no evidence of harm from the ketamine’s use in patients with TBI.

APOE-ε4 Is Associated With Reduced Verbal Memory Performance and Higher Emotional, Cognitive, and Everyday Executive Function Symptoms Two Months After Mild Traumatic Brain Injury

Background

Substantial variance exists in outcomes after mild traumatic brain injury (MTBI), and these differences are not fully explained by injury characteristics or severity. Genetic factors are likely to play a role in this variance.

Objectives

The aim of this study was to examine associations between the apolipoprotein (APOE)-ε4 allele and memory measures at two months post-MTBI and to evaluate whether subjective cognitive and affective symptoms were associated with APOE-ε4 status. Based on previous research, it was hypothesized that APOE-ε4 carriers would show poorer verbal memory performance compared to APOE-ε4 non-carriers.

Methods

Neuropsychological data at two months post-injury and blood samples that could be used to assess APOE genotype were available for 134 patients with MTBI (mean age 39.2 years, 62% males, 37% APOE-ε4 carriers). All patients underwent computed tomography at hospital admission and magnetic resonance imaging four weeks post-injury.

Results

The APOE-ε4 + status was associated with decreased immediate memory recall (p = 0.036; β = −0.10, 95% CI [−0.19, −0.01]). Emotional, cognitive, and everyday executive function symptoms at two months post-injury were significantly higher in APOE-ε4 carriers compared to non-carriers.

Conclusion

The APOE-ε4+ allele has a negative effect on verbal memory and symptom burden two months after MTBI.

Traumatic Brain Injury and Gut Brain Axis: The Disruption of an Alliance

BACKGROUND

Traumatic brain injury (TBI) can be considered a "silent epidemic", causing morbidity, disability, and mortality in all age cohorts. Therefore, a greater understanding of the underlying pathophysiological intricate mechanisms and interactions with other organs and systems is necessary to intervene not only in the treatment but also in the prevention of complications. In this complex of reciprocal interactions, the complex brain-gut axis has captured a growing interest.

SCOPE

The purpose of this manuscript is to examine and systematize existing evidence regarding the pathophysiological processes that occur following TBI and the influences exerted on these by the brain-gut axis.

LITERATURE REVIEW

A systematic review of the literature was conducted according to the PRISMA methodology. On the 8th of October 2021, two independent databases were searched: PubMed and Scopus. Following the inclusion and exclusion criteria selected, 24 (12 from PubMed and 12 from Scopus) eligible manuscripts were included in the present review. Moreover, references from the selected articles were also updated following the criteria mentioned above, yielding 91 included manuscripts.

DISCUSSION

Published evidence suggests that the brain and gut are mutually influenced through four main pathways: microbiota, inflammatory, nervous, and endocrine.

CONCLUSION

These pathways are bidirectional and interact with each other. However, the studies conducted so far mainly involve animals. An autopsy methodological approach to corpses affected by traumatic brain injury or intestinal pathology could represent the keystone for future studies to clarify the complex pathophysiological processes underlying the interaction between these two main systems.

Accidental identification of peritoneal encapsulation during an autopsy after a car accident

Peritoneal encapsulation is a rare congenital pathological condition. Typical of this pathology is the presence of an accessory peritoneal flap that encloses the entire mass of the small intestine. Subjects with this condition often do not show symptoms and, in most cases, finding of it is accidental. We report a case of peritoneal encapsulation, not previously identified and found during an autopsy; the deceased, positive for HIV and affected by a Kaposi's sarcoma, died following a road accident. Unlike other cases in the literature, the peritoneum encapsulated all abdominal organs and not only small intestines. Notwithstanding, there were no signs of intestinal ischaemia or intestinal obstruction.

Subdural and epidural hematoma occurrence in relation to the head impact site: An autopsy study

Blunt head injury is a major public health and socioeconomic problem causing death and disability particularly among the young population throughout the world. The purpose of the present study was to evaluate if the impact site is correlated with the subdural and epidural hematoma occurrence. A retrospective analysis of consecutive autopsy cases submitted to our Department during a 5-year period was performed. The basic criterion for inclusion in the study was death due to blunt head injury. The recorded variables included the circumstances of death, the existence, and location of head injuries, the primary impact site, age, gender, and toxicological results. A total number of 683 fatal head injury cases was recorded, with most of them being male (74.1%). In 424 cases (62.1%) fatal head injuries were due to road traffic accidents. Fall (from height or on the ground) was the cause of death in 220 (32.2%) cases followed by inflicted impact-assault in 26 (3.8%) cases. A subdural hematoma was found more frequently (26.9%) than epidural (5.0%). Epidural hematomas were found only under the primary impact site, whereas subdural hematomas were coup, contrecoup, or bilateral. An epidural hematoma was found to be almost 5 times more frequent in cases in which a subdural hematoma was present. A higher proportion of subdural, as well as epidural hematoma, was found when the site of impact was the temporal region, followed by the parietal one. Sex did not exert any influence on the probability of subdural and epidural hematoma, whereas for age, a 10% increase in the probability of subdural hematoma occurrence was observed with 10-year age increase.