Concurrent Brain Injury Research Articles

A combat casualty relevant dismounted complex blast injury model in swine.

Improvised explosive devices have resulted in a unique polytrauma injury pattern termed dismounted complex blast injury (DCBI), which is frequent in the modern military theater. Dismounted complex blast injury is characterized by extremity amputations, junctional vascular injury, and blast traumatic brain injury (bTBI). We developed a combat casualty relevant DCBI swine model, which combines hemorrhagic shock (HS) and tissue injury (TI) with a bTBI, to study interventions in this unique and devastating military injury pattern. A 50-kg male Yorkshire swine were randomized to the DCBI or SHAM group (instrumentation only). Those in the DCBI group were subjected to HS, TI, and bTBI. The blast injury was applied using a 55-psi shock tube wave. Tissue injury was created with bilateral open femur fractures. Hemorrhagic shock was induced by bleeding from femoral arteries to target pressure. A resuscitation protocol modified from the Tactical Combat Casualty Care guidelines simulated battlefield resuscitation for 240 minutes. Eight swine underwent the DCBI model and five were allocated to the SHAM group. In the DCBI model the mean base excess achieved at the end of the HS shock was -8.57 ± 5.13 mmol·L -1 . A significant coagulopathy was detected in the DCBI model as measured by prothrombin time (15.8 seconds DCBI vs. 12.86 seconds SHAM; p = 0.02) and thromboelastography maximum amplitude (68.5 mm DCBI vs. 78.3 mm in SHAM; p = 0.0003). For the DCBI models, intracranial pressure (ICP) increased by a mean of 13 mm Hg, reaching a final ICP of 24 ± 7.7 mm Hg. We created a reproducible large animal model to study the combined effects of severe HS, TI, and bTBI on coagulation and ICP in the setting of DCBI, with significant translational applications for the care of military warfighters. Within the 4-hour observational period, the swine developed a consistent coagulopathy with a concurrent brain injury evidenced by increasing ICP.

Lung-protective ventilation and adjunctive strategies to manage respiratory failure: are they safe in the neurological patient?

The coexistence of neurological injury and respiratory failure is common in intensive care. This article provides a contemporary overview of the safety and efficacy of different strategies for mechanical ventilation and adjunctive respiratory approaches in patients with acute brain injury. Available evidence indicates that lung-protective ventilation (LPV) can be implemented safely in a range of patients with concurrent respiratory failure and brain injury of different etiologies; however, the clinical efficacy of LPV in this setting needs to be established. In patients who have severe acute respiratory distress syndrome (ARDS) and brain injury, adjunctive measures (neuromuscular blocker drug infusions, prone positioning, extracorporeal membrane oxygenation) may be considered, although the neurophysiological impact and safety of these techniques need further investigation. Intracranial pressure and other neuromonitoring techniques may be of value to ensure optimal management of mechanical ventilation and adjunctive measures in this population. Research is needed to determine the safety, feasibility, and efficacy of LPV and adjunctive approaches for managing patients with concurrent brain injury and respiratory failure.

Dementia, Depression, and Associated Brain Inflammatory Mechanisms after Spinal Cord Injury.

Evaluation of the chronic effects of spinal cord injury (SCI) has long focused on sensorimotor deficits, neuropathic pain, bladder/bowel dysfunction, loss of sexual function, and emotional distress. Although not well appreciated clinically, SCI can cause cognitive impairment including deficits in learning and memory, executive function, attention, and processing speed; it also commonly leads to depression. Recent large-scale longitudinal population-based studies indicate that patients with isolated SCI (without concurrent brain injury) are at a high risk of dementia associated with substantial cognitive impairments. Yet, little basic research has addressed potential mechanisms for cognitive impairment and depression after injury. In addition to contributing to disability in their own right, these changes can adversely affect rehabilitation and recovery and reduce quality of life. Here, we review clinical and experimental work on the complex and varied responses in the brain following SCI. We also discuss potential mechanisms responsible for these less well-examined, important SCI consequences. In addition, we outline the existing and developing therapeutic options aimed at reducing SCI-induced brain neuroinflammation and post-injury cognitive and emotional impairments.

The epidemiology of childhood and adolescent traumatic spinal cord injury in the United States: 2007-2010.

The burden of acute traumatic spinal cord injury (TSCI) among U. S. children and adolescents was last described over a decade ago using inpatient data. We describe cumulative incidence, mortality, discharge disposition, and inflation-adjusted charges of childhood and adolescent TSCI in the U.S. using emergency department (ED) data from the Nationwide Emergency Department Sample (2007-2010). Patients ages 17 years and younger with a diagnosis of acute TSCI were identified using the International Classification of Diseases, Ninth Revision (ICD-9) diagnosis codes 806.* and 952.* (N = 6132). The cumulative incidence of childhood and adolescent TSCI averaged 17.5 per million population per year. The median age at presentation was 15 years (interquartile range [IQR] = 12-16) and the majority of patients were male (72.5%). The overall median new injury severity score (NISS) was 16 (IQR = 9-27), remaining unchanged during the study duration (p=0.703). Children 5 years and younger were more likely to be injured from a road traffic accident (RTA; 50.9%), sustain C1-C4 injuries (47.4%), have more severe injury (median NISS = 22; IQR = 13-29), and concurrent brain injury (24%) compared to older children and adolescents, p<0.001. Firearms were implicated in 8.3% of injuries, of which 94.7% were among adolescents ages 13-17 years. Of the 35 TSCI-related ED deaths, 40% occurred among children ages 5 years and younger. 62.4% of patients required inpatient admission. Despite stable cumulative incidence and overall injury severity, ED treatment charge per visit increased on average $1394 from $3495 in 2007 to $4889 in 2010 (p=0.008). RTA-related TSCI disproportionately affects young children, while firearm-related TSCI is most common among adolescents. These findings inform TSCI prevention strategies. Prevention may be key in mitigating rising healthcare cost.

Prospective Study of Validity of Neurologic Signs in Predicting Positive Cranial Computed Tomography following Minor Head Trauma

The ability to discriminate among a large number of patients with mild head injury to detect those most likely to have an intracranial abnormality may offer an advantage in mass-casualty situations and when clinical needs exceed diagnostic capabilities. In patients with mild head injury (Glasgow Coma Scale score = 13-15), the likelihood of intracranial abnormality, as defined by cranial computed tomography (CT), varies according to presenting neurologic signs and symptoms. This prospective study consisted of 152 patients with blunt head trauma and one or more of the following: initial loss of consciousness (LOC), headache, vomiting, convulsions, or amnesia. All underwent cranial CT within one hour of presentation. Positive CT findings were defined as cerebral contusion, extra-axial hematoma, intra-ventricular or subarachnoid hemorrhage, brain edema, and skull fracture. Clinical findings were tabulated and compared with CT findings. The most common symptoms were headache (61%) followed by followed by LOC (45%), vomiting (39%), amnesia (29%), and convulsions (4%). Convulsions were the most predictive of a CT positive finding (80%); history of LOC was least predictive (29%). The presence of two or more clinical findings tended to increase the likelihood of intracranial abnormality, but the association was neither consistent nor additive. Convulsions occurring in a patient with mild head injury are highly predictive of a positive intracranial finding on CT. Headache, amnesia, and vomiting are each likely to show positive findings in approximately 40-45% of cases. Although the least predictive of the neurologic findings studied, loss of consciousness still correlates with a positive cranial CT in 29% of cases. More than one sign or symptom increases the likelihood of concurrent brain injury.

Head injuries and skull radiography: clinical factors predicting a fracture

Five hundred and ninety-eight cases were studied where the patients had been subjected to skull radiography because of a head injury. Concussion had been established in 231 patients and a more severe brain injury in 8. Forty-nine patients (8.2 per cent) had skull fractures. The relative frequency of fractures was the highest among those aged between 40 and 59 years (16 per cent). From among 16 variables, either clinical or pertaining to the history, 4 had clearly sustained a fracture of the skull, the statistically significant features being amnesia, unconsciousness for over 30 minutes, a wound and subcutaneous haematoma in the scalp and a reduced level of consciousness. On the basis of these signs the patients could be divided into two groups which differed in the frequency of skull fractures by a factor of five. The skull fracture was not observed to have influenced the patient's care or recovery, particularly if the patient had a concurrent brain injury. Based on the results, the indications for skull radiography in patients with head injuries can be identified and this can reduce the need for X-ray examinations to one-half and still reveal 80 per cent of skull fractures.

Cytomegalic Inclusion Disease of the Developing Fetus: A Potentially Preventable Cause of Congenital Mental Defect

Infection after infancy by salivary gland virus produces an apparently harmless salivary cytomegaly, Huge inclusion bodies develop which equal nuclei in size. Specific antibodies appear in the serum. The infection is a serious risk to the fetus when transmitted during early pregnancy, despite lack of clinical illness shown by the mother. Actively growing fetal tissues, especially those of brain and liver, show necrosis without reaction which progresses silently for up to six months before birth. Shortly after bjrth, a characteristic clinical picture may supervene which imitates “erythroblastosis fetalis” or “neonatal hepatitis.” The concurrent brain injury has a highly characteristic periventricular location. Full cerebral development is blocked, leading to mental defect, spasticity, micro or obstructive-hydrocephaly, sometimes recognizable at birth.