Classification of a traumatic brain injury: the Glasgow Coma scale is not enough

Fluid-Based Protein Biomarkers in Traumatic Brain Injury: The View from the Bedside

There has been an explosion of research into biofluid (blood, cerebrospinal fluid, CSF)-based protein biomarkers in traumatic brain injury (TBI) over the past decade. The availability of very large datasets, such as CENTRE-TBI and TRACK-TBI, allows for correlation of blood- and CSF-based molecular (protein), radiological (structural) and clinical (physiological) marker data to adverse clinical outcomes. The quality of a given biomarker has often been framed in relation to the predictive power on the outcome quantified from the area under the Receiver Operating Characteristic (ROC) curve. However, this does not in itself provide clinical utility but reflects a statistical association in any given population between one or more variables and clinical outcome. It is not currently established how to incorporate and integrate biofluid-based biomarker data into patient management because there is no standardized role for such data in clinical decision making. We review the current status of biomarker research and discuss how we can integrate existing markers into current clinical practice and what additional biomarkers do we need to improve diagnoses and to guide therapy and to assess treatment efficacy. Furthermore, we argue for employing machine learning (ML) capabilities to integrate the protein biomarker data with other established, routinely used clinical diagnostic tools, to provide the clinician with actionable information to guide medical intervention.

Effects of altitude changes on mild-to-moderate closed-head injury in rats following acute high-altitude exposure

Mild-to-moderate closed-head injury (mmCHI) is an acute disease induced by high-altitudes. It is general practice to transfer patients to lower altitudes for treatment, but the pathophysiological changes at different altitudes following mmCHI remain unknown. The present study simulated acute high-altitude exposure (6,000 m above sea level) in rats to establish a model of mmCHI and recorded their vital signs. The rats were then randomly assigned into different altitude exposure groups (6,000, 4,500 and 3,000 m) and neurological severity score (NSS), body weight (BW), brain magnetic resonance imaging (MRI), brain water content (BWC) and the ratio of BW/BWC at 6, 12 and 24 h following mmCHI, and the glial fibrillary acidic protein levels were analysed in all groups. The results revealed that within the first 24 h following acute high-altitude exposure, mmCHI induced dehydration, brain oedema and neuronal damage. Brain injury in rats was significantly reversed following descent to 4,500 m compared with the results from 6,000 or 3,000 m. The results indicated that subjects should be transported as early as possible. Furthermore, avoiding large-span descent altitude was beneficial to reduce neurological impairment. The examination of brain-specific biomarkers and MRI may further be useful in determining the prognosis of high-altitude mmCHI. These results may provide guidance for rescuing high altitude injuries.

Prognostic utility of circulating nucleic acids in acute brain injuries

INTRODUCTION

Acute brain injuries represent major causes of morbidity and mortality worldwide. Nevertheless, therapeutic options are centered mainly on supportive care, and accurate prognosis prediction following traumatic brain injury (TBI) or stroke remains a challenge in clinical settings. Areas covered: Circulating DNA and RNA have shown potential as predictive molecules in acute brain injuries. In particular, plasma cell-free DNA (cfDNA) levels have been correlated to severity, mortality, and outcome after TBI and stroke. The real-time quantitative polymerase chain reaction (qPCR) is the most widely used technique for determination of cfDNA in brain injuries; however, to consider the use of cfDNA in emergency settings, a quicker and easier methodology for detection should be established. A recent study proposed detection of cfDNA applying a rapid fluorescent test that showed compatible results with qPCR. Expert commentary: As a promising perspective, detection of cfDNA levels using simple, rapid, and cheap methodology has potential to translate to clinic as a point-of-care marker, supporting the clinical decision-making in emergency care settings. Conversely, miRNA profiles may be used as signatures to determine the type and severity of injuries. Additionally, in the future, some miRNAs may constitute innovative neurorestorative therapies without the common hurdles associated with cell therapy.

Paediatric horse-related trauma

AIM

This retrospective cohort study reported on the epidemiology of horse-related injuries for patients presenting to the only tertiary paediatric trauma hospital in Queensland. The secondary outcome was to examine the use of helmets and adult supervision. Traumatic brain injury (TBI) was examined in relation to helmet use. Morbidity and mortality were also recorded.

METHODS

Included were all patients presenting with any horse-related trauma to the Royal Children's Hospital in Brisbane from January 2008 to August 2014. Data were retrospectively collected on patient demographics, hospital length of stay (LOS), mechanism of injury (MOI), safety precautions taken, diagnoses and surgical procedures performed.

RESULTS

Included in the analysis were 187 incidents involving 171 patients. Most patients were aged 12-14 years (36.9%) and female (84.5%). The most common MOI were falls while riding horses (97.1%). Mild TBI (24.6%) and upper limb fractures (20.9%) were common injuries sustained. Patients who wore helmets had significantly reduced hospital LOS and severity of TBI when compared with those who did not wear helmets (P < 0.001 and P = 0.028, respectively). Morbidity was reported in 7.5% of patients. There were three deaths in Queensland.

CONCLUSION

Helmet use is recommended for non-riders when handling horses, in addition to being a compulsory requirement whilst horse riding. Prompts in documentation may assist doctors to record the use of safety attire and adult supervision. This will allow future studies to further investigate these factors in relation to clinical outcomes.

Neurotrauma: The Crosstalk between Neurotrophins and Inflammation in the Acutely Injured Brain

Traumatic brain injury (TBI) is a major cause of morbidity and mortality among young individuals worldwide. Understanding the pathophysiology of neurotrauma is crucial for the development of more effective therapeutic strategies. After the trauma occurs, immediate neurologic damage is produced by the traumatic forces; this primary injury triggers a secondary wave of biochemical cascades together with metabolic and cellular changes, called secondary neural injury. In the scenario of the acutely injured brain, the ongoing secondary injury results in ischemia and edema culminating in an uncontrollable increase in intracranial pressure. These areas of secondary injury progression, or areas of “traumatic penumbra”, represent crucial targets for therapeutic interventions. Neurotrophins are a class of signaling molecules that promote survival and/or maintenance of neurons. They also stimulate axonal growth, synaptic plasticity, and neurotransmitter synthesis and release. Therefore, this review focuses on the role of neurotrophins in the acute post-injury response. Here, we discuss possible endogenous neuroprotective mechanisms of neurotrophins in the prevailing environment surrounding the injured areas, and highlight the crosstalk between neurotrophins and inflammation with focus on neurovascular unit cells, particularly pericytes. The perspective is that neurotrophins may represent promising targets for research on neuroprotective and neurorestorative processes in the short-term following TBI.

A population-based study on epidemiology of intensive care unit treated traumatic brain injury in Iceland

BACKGROUND

Traumatic brain injury is a worldwide health issue and a significant cause of preventable deaths and disabilities. We aimed to describe population-based data on intensive care treated traumatic brain injury in Iceland over 15 years period.

METHODS

Retrospective review of all intensive care unit admissions due to traumatic brain injury at The National University Hospital of Iceland 1999-2013. Data were collected on demographics, mechanism of injury, alcohol consumption, glasgow come scale upon admission, Injury Severity Scoring, acute physiology and chronic health evaluation II score, length of stay, interventions and mortality (defined as glasgow outcome score one). All computerized tomography scans were reviewed for Marshall score classification.

RESULTS

Intensive care unit admissions due to traumatic brain injury were 583. The incidence decreased significantly from 14/100.000/year to 12/100.000/year. Males were 72% and the mean age was 41 year. Majority of patients (42%) had severe traumatic brain injury. The most common mechanism of injury was a fall from low heights (36.3%). The mortality was 18.2%. Increasing age, injury severity score, Marshall score and acute physiology and chronic health evaluation II score are all independent risk factors for death. Glasgow coma scale was not an independent prognostic factor for outcome.

CONCLUSIONS

Incidence decreased with a shift in injury mechanism from road traffic accidents to falls and an increased rate of traumatic brain injury in older patients following a fall from standing or low heights. Mortality was higher in older patients falling from low heights than in younger patients suffering multiple injuries in road traffic accidents. Age, injury severity score, acute physiology and chronic health evaluation II score and Marshall score are good prognostic factors for outcome. Traumatic brain injury continues to be a considerable problem and the increase in severe traumatic brain injury in the middle age and older age groups after a seemingly innocent accident needs a special attention.

Subdural hematoma as a major determinant of short-term outcomes in traumatic brain injury

OBJECTIVE Early radiographic findings in patients with traumatic brain injury (TBI) have been studied in hopes of better predicting injury severity and outcome. However, prior attempts have generally not considered the various types of intracranial hemorrhage in isolation and have typically not excluded patients with potentially confounding extracranial injuries. Therefore, the authors examined the associations of various radiographic findings with short-term outcome to assess the potential utility of these findings in future prognostic models. METHODS The authors retrospectively identified 1716 patients who had experienced TBI without major extracranial injuries, and categorized them into the following TBI subtypes: subdural hematoma (SDH), traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage (which included intraventricular hemorrhage), and epidural hematoma. They specifically considered isolated forms of hemorrhage, in which only 1 subtype was present. RESULTS In general, the presence of an isolated SDH was more likely to result in worse outcomes than the presence of other isolated forms of traumatic intracranial hemorrhage. Discharge to home was less likely and perihospital mortality rates were generally higher in patients with SDH. These findings were not simply related to age and were not fully captured by the admission Glasgow Coma Scale (GCS) score. The presence of SDH had a much higher sensitivity for poor outcome than the presence of other TBI subtypes, and was more sensitive for these poor outcomes than having a low GCS score (3-8). CONCLUSIONS In these ways, SDH was the most important finding associated with poor outcome, and the authors show that consideration of SDH, specifically, can augment age and GCS score in classification and prognostic models for TBI.

Epidemiology and clinical characteristics of traumatic brain injury in Lebanon: A systematic review

BACKGROUND

Traumatic brain injury (TBI) is a debilitating medical and emerging public health problem that is affecting people worldwide due to a multitude of factors including both domestic and war-related acts. The objective of this paper is to systematically review the status of TBI in Lebanon - a Middle Eastern country with a weak health system that was chartered by several wars and intermittent outbursts of violence - in order to identify the present gaps in knowledge, direct future research initiatives and to assist policy makers in planning progressive and rehabilitative policies.

METHODS

OVID/Medline, PubMed, Scopus databases and Google Scholar were lastly searched on April 15, 2016 to identify all published research studies on TBI in Lebanon. Studies published in English, Arabic or French that assessed Lebanese patients afflicted by TBI in Lebanon were warranting inclusion in this review. Case reports, reviews, biographies and abstracts were excluded. Throughout the whole review process, reviewers worked independently and in duplicate during study selection, data abstraction and methodological assessment using the Downs and Black Checklist.

RESULTS

In total, 11 studies were recognized eligible as they assessed Lebanese patients afflicted by TBI on Lebanese soils. Considerable methodological variation was found among the identified studies. All studies, except for two that evaluated domestic causes such as falls, reported TBI due to war-related injuries. Age distribution of TBI victims revealed two peaks, young adults between 18 and 40 years, and older adults aged 60 years and above, where males constituted the majority. Only three studies reported rates of mild TBI. Mortality, rehabilitation and systemic injury rates were rarely reported and so were the complications involved; infections were an exception.

CONCLUSION

Apparently, status of TBI in Lebanon suffers from several gaps which need to be bridged through implementing more basic, epidemiological, clinical and translational research in this field in the future.

Correlation between Glasgow Coma Scale and brain computed tomography-scan findings in head trauma patients

Background:

The study aimed to assess the relationship between computed tomography (CT) scan findings and Glasgow Coma Scale (GCS) score with the purpose of introducing GCS scoring system as an acceptable alternative for CT scan to clinically management of brain injuries in head trauma patients.

Materials and Methods:

This study was conducted on hospitalized patients with the complaints of head trauma. The severity of the head injury was assessed on admission by the GCS score and categorized as mild, moderate, or severe head injury.

Results:

Of all study subjects, 80.5% had GCS 13–15 that among those, 45% had GCS 15. Furthermore, 10.5% had GCS ranged 9–12 and 9% had GCS <8. Of all subjects, 54.5% had abnormal CT findings that of them, 77.1% categorized as mild head injury, 11.0% had a moderate head injury, and 11.9% had a severe head injury. Furthermore, of those with GCS 15, 41.0% had abnormal CT scan. Of all patients with abnormal CT findings, 33.0% underwent surgery that 61.1% categorized in mild head injury group, 13.9% categorized in moderate head injury group, and 22.2% categorized in severe head injury group. Of those with GCS equal to 15, only 27.0% underwent surgery.

Conclusion:

The use of GCS score for assessing the level of injury may not be sufficient and thus considering CT findings as the gold standard, the combination of this scoring system and other applicable scoring systems may be more applicable to stratify brain injury level.

Development and Preliminary Validation of the Acute Brain Injury Physiotherapy Assessment (ABIPA)

Background and aims: For patients with a severe brain injury there is no objective physiotherapy assessment tool that is responsive to the incremental changes in motor recovery in the acute stage. The aims of this study were to identify the items of neuro-motor recovery and scoring criteria for the Acute Brain Injury Physiotherapy Assessment (ABIPA) and determine responsiveness to change and concurrent validity against accepted standard measures of consciousness and physical function in the severe brain injury population.

Method: The literature was searched and an expert consensus panel of experienced clinical physiotherapists informed item selection and developed practical assessment guidelines. The ABIPA was investigated for responsiveness to change and concurrent validity against the Glasgow Coma Scale (GCS), Clinical Outcome Variable Scale (COVS) and Motor Assessment Scale (MAS). Eleven patients (9 males; cohort 41 ± 18 years) with moderate/severe brain injury were recruited, and assessed on days 1, 3, 7 and then weekly until discharge.

Results: The ABIPA demonstrated good to excellent correlations overall with the GCS (rho > .76, p ≤ .001), COVS (rho > .82, p ≤ .001) and MAS (rho > 0.66, p ≤ .001). On day 3, the ABIPA showed the greatest responsiveness to change (standardised response means (SRM) > .83) compared to other measures (SRMs < .77). At discharge all tools demonstrated change in neuro-motor recovery.

Conclusions: The ABIPA is a promising tool for detecting incremental changes in neuro-motor recovery early after severe brain injury.

Evaluation of classification systems for nonspecific idiopathic orbital inflammation

PURPOSE

To systematically analyze existing classification systems for idiopathic orbital inflammation (IOI) and propose and test a new best practice classification system.

METHODS

A systematic literature search was conducted to find all studies that described and applied a classification system for IOI. Classification categories used in more than two studies were extracted, and criteria for these categories were defined using common descriptors. Using patient data, these newly defined classification systems were evaluated. Reliability was tested by inter- and intrarater agreement of two raters and distinction tested by evaluating clinical differences among classification categories. Feasibility, face validity, and content validity were qualitatively tested.

RESULTS

The most frequently encountered IOI classification systems were based on onset (acute, chronic), histopathology (classic, granulomatous, sclerosing), or localization (diffuse, extraocular muscle, lacrimal gland, sclera, optic nerve). Systems based on histopathology and localization showed good reliability (κ values range 0.74-0.89), were easy to apply (feasibility), and described the biologic process (face validity). Because of static sampling, histopathology-based systems had moderate content validity and moderate distinction between classification categories. Being a static measure, localization had moderate content validity, but good distinction. It was found that content validity was improved by combining histopathology and localization into a two-dimensional classification system.

CONCLUSIONS

This combined histopathology and localization-based classification system provides a repeatable, easy to use, plausible, and complete classification system that can be used to further advance the research of IOI.

Pupil evaluation in addition to Glasgow Coma Scale components in prediction of traumatic brain injury and mortality

Background

Early diagnosis and prediction of traumatic brain injury (TBI) is essential for determining treatment strategies and allocating resources. This study evaluated the predictive accuracy of Glasgow Coma Scale (GCS) verbal, motor and eye components alone, or in addition to pupil size and reactivity, for TBI.

Methods

A retrospective cohort analysis of data from 51 425 severely injured patients registered in the Trauma Registry of the German Society for Trauma Surgery from 1993 to 2009 was undertaken. Only directly admitted patients alive on admission and with complete data on GCS, pupil size and pupil reactivity were included. The unadjusted predictive roles of GCS components and pupil parameters, alone or in combination, were modelled using area under the receiver operating characteristic (AUROC) curve analyses and multivariable logistic regression regarding presence of TBI and death.

Results

Some 24 115 patients fulfilled the study inclusion criteria. Best accuracy for outcome prediction was found for pupil reactivity (AUROC 0·770, 95 per cent confidence interval 0·761 to 0·779) and GCS motor component (AUROC 0·797, 0·788 to 0·805), with less accuracy for GCS eye and verbal components. The combination of pupil reactivity and GCS motor component (AUROC 0·822, 0·814 to 0·830) outmatched the predictive accuracy of GCS alone (AUROC 0·808, 0·800 to 0·815). Pupil reactivity and size were significantly correlated (rs = 0·56, P &lt; 0·001). Patients displaying both unequal pupils and fixed pupils were most likely to have TBI (95·1 per cent of 283 patients). Good outcome (Glasgow Outcome Scale score 4 or more) was documented for only 1929 patients (8·0 per cent) showing fixed and bilateral dilated pupils.

Conclusion

The best predictive accuracy for presence of TBI was obtained using the GCS components. Pupil reactivity together with the GCS motor component performed best in predicting death.

Pupillary reactivity as an early indicator of increased intracranial pressure: The introduction of the Neurological Pupil index

Background

This paper introduces the 7/5/2011al Pupil index (NPi), a sensitive measure of pupil reactivity and an early indicator of increasing intracranial pressure (ICP). This may occur in patients with severe traumatic brain injury (TBI), aneurysmal subarachnoid hemorrhage, or intracerebral hemorrhage (ICH).

Methods

134 patients (mean age 46 years, range 18–87 years, 54 women and 80 men) in the intensive care units at eight different clinical sites were enrolled in the study. Pupillary examination was performed using a portable hand-held pupillometer.

Results

Patients with abnormal pupillary light reactivity had an average peak ICP of 30.5 mmHg versus 19.6 mmHg for the normal pupil reactivity population (P = 0.0014). Patients with “nonreactive pupils” had the highest peaks of ICP (mean = 33.8 mmHg, P = 0.0046). In the group of patients with abnormal pupillary reactivity, we found that the first evidence of pupil abnormality occurred, on average, 15.9 hours prior to the time of the peak of ICP.

Conclusions

Automated pupillary assessment was used in patients with possible increased ICP. Using NPi, we were able to identify a trend of inverse relationship between decreasing pupil reactivity and increasing ICP. Quantitative measurement and classification of pupillary reactivity using NPi may be a useful tool in the early management of patients with causes of increased ICP.