Traumatic Brain Injury Factors Research Articles

Metopism: An anatomical variant that the physician should take into account

Introduction: During childhood these sutures close, forming the characteristic sutures of the skull, one of these is the frontal suture, which joins the two frontal bones perfectly, simulating a single frontal bone. However, this suture can persist into adulthood, giving an anatomical variant known as metopism. Case Report: A 19-year-old Mexican male presented with high-energy trauma related to a traffic accident while riding a motorcycle without wearing a safety helmet. A simple skull computed tomography (CT) was considered due to moderate risk factors for traumatic brain injury (TBI), based on the Master’s classification, progressive headache, presence of hematoma, facial injuries. When performing the simple skull tomography, persistence of the metopic suture was observed. Conclusion: Metopism has generally been reported as a postmortem finding in population studies aimed at its search. This report has special attention because it was identified as a differential diagnosis of a skull fracture following a traumatic brain injury. The important finding that differentiates metopic suture from a fracture is the presence of serrated and sclerotic edges. A persistent metopic suture can be easily diagnosed by an anteriorposterior radiograph.

Cumulative Blast Exposure During a Military Career Negatively Impacts Recovery from Traumatic Brain Injury.

Sub-concussive injuries have emerged as an important factor in the long-term brain health of athletes and military personnel. The objective of this study was to explore the relationship between service member and veterans (SMVs) lifetime blast exposure and recovery from a traumatic brain injury (TBI). A total of 558 SMVs with a history of TBI were examined. Lifetime blast exposure (LBE) was based on self-report (M = 79.4, standard deviation = 392.6; range = 0-7500) categorized into three groups: Blast Naive (n = 121), Low LBE (n = 223; LBE range 1-9), and High LBE (n = 214; LBE >10). Dependent variables were the Neurobehavioral Symptom Inventory (NSI) and Post-traumatic Stress Disorder Checklist-Civilian (PCL-C) and the Traumatic Brain Injury Quality of Life (TBI-QOL). Analyses controlled for demographic factors (age, gender, and race) as well as TBI factors (months since index TBI, index TBI severity, and total number lifetime TBIs). The Blast Naive group had significantly lower NSI and PCL-C scores compared with the Low LBE group and High LBE group, with small to medium effect sizes. On the TBI-QOL, the Blast Naïve group had better quality life on 10 of the 14 scales examined. The Low LBE did not differ from the High LBE group on the PCL-C, NSI, or TBI-QOL. Blast exposure over an SMV's career was associated with increased neurobehavioral and post-traumatic stress symptoms following a TBI. The influence of psychological trauma associated with blasts may be an important factor influencing symptoms as well as the accuracy of self-reported estimates of LBE.

Outcomes and associated factors of traumatic brain injury among adult patients treated in Amhara regional state comprehensive specialized hospitals

BackgroundGlobally, traumatic brain injury is the leading cause of death and disability which affects more than 69 million individuals a year.ObjectiveThis study aimed to assess the outcome and associated factors of traumatic brain injury among adult patients treated in Amhara regional state comprehensive specialized hospitals.MethodInstitutional-based cross-sectional study design was conducted from January 1, 2018, to December 30, 2020. A simple random sampling technique was used and a checklist was used to extract data between March 15 and April 15, 2021. The data were entered into Epi-data version 4.2 and exported to SPSS version 25 for analysis after being checked for consistency. Associated variables with outcomes of traumatic brain injury were determined by a binary logistic regression model. The degree of association was interpreted by using AOR and a 95% confidence interval with a p-value less than or equal to 0.05 at 95% CI was considered statistically significant.ResultIn this study road traffic injury was the most frequent cause of traumatic brain injuries among adult patients, accounting for 181 (37.5%), followed by assault, accounting for 117 (24.2%) which affects adult age groups. One-third of the participant had a moderate Glasgow coma scale of 174(36%). Only 128(26.8%) patients arrived within one hour. One hundred sixty, 160 (33.1%) of patients had a mild traumatic brain injury, whereas, 149(36%) of patients had a severe traumatic brain injury. Regarding computerized tomography scans findings, the hematoma was the most common (n = 163, 33.7%). Ninety-one, 91(18.8%) of participants had cerebrospinal fluid otorrhea, and, 92(19%) were diagnosed with a positive battle sign. The overall prevalence of unfavorable outcomes after traumatic brain injury was found to be 35.2% (95%CI (30.8–39.1). Having additional Injury, hypoxia, time to hospital presentation after 24 h, severe Glasgow Coma Scale, moderate Glasgow Coma Scale, tachypnea, bradypnea, and cerebrospinal fluid Othorrhea, were factors associated with unfavorable outcomes.Conclusion and recommendationIn this study, the overall unfavorable outcome was experienced by about four out of every 10 victims of traumatic brain injury. Time of arrival > 24 h, low Glasgow coma scale, additional injury, Cerebrospinal fluid otorrhea, abnormal respiration, and hypoxia were significant predictors of unfavorable outcomes. To reduce the adverse effects of traumatic brain injury in adults, it is therefore desirable to guarantee safe road traffic flow and improve health care services.

KDM4A, involved in the inflammatory and oxidative stress caused by traumatic brain injury-hemorrhagic shock, partly through the regulation of the microglia M1 polarization

BackgroundMicroglial polarization and the subsequent neuroinflammatory response and oxidative stress are contributing factors for traumatic brain injury (TBI) plus hemorrhagic shock (HS) induced brain injury. In the present work, we have explored whether Lysine (K)-specific demethylase 4 A (KDM4A) modulates microglia M1 polarization in the TBI and HS mice.ResultsMale C57BL/6J mice were used to investigate the microglia polarization in the TBI + HS model in vivo. Lipopolysaccharide (LPS)-induced BV2 cells were used to examine the mechanism of KDM4A in regulating microglia polarization in vitro. We found that TBI + HS resulted in neuronal loss and microglia M1 polarization in vivo, reflected by the increased level of Iba1, tumor necrosis factor (TNF)-α, interleukin (IL)-1β, malondialdehyde (MDA) and the decreased level of reduced glutathione (GSH). Additionally, KDM4A was upregulated in response to TBI + HS and microglia were among the cell types showing the increased level of KDM4A. Similar to the results in vivo, KDM4A also highly expressed in LPS-induced BV2 cells. LPS-induced BV2 cells exhibited enhanced microglia M1 polarization, and enhanced level of pro-inflammatory cytokines, oxidative stress and reactive oxygen species (ROS), while this enhancement was abolished by the suppression of KDM4A.ConclusionAccordingly, our findings indicated that KDM4A was upregulated in response to TBI + HS and microglia were among the cell types showing the increased level of KDM4A. The important role of KDM4A in TBI + HS-induced inflammatory response and oxidative stress was at least partially realized through regulating microglia M1 polarization.

Genetic deletion of Krüppel-like factor 11 aggravates traumatic brain injury

BackgroundThe long-term functional recovery of traumatic brain injury (TBI) is hampered by pathological events, such as parenchymal neuroinflammation, neuronal death, and white matter injury. Krüppel-like transcription factor 11 (KLF 11) belongs to the zinc finger family of transcription factors and actively participates in various pathophysiological processes in neurological disorders. Up to now, the role and molecular mechanisms of KLF11 in regulating the pathogenesis of brain trauma is poorly understood.MethodsKLF11 knockout (KO) and wild-type (WT) mice were subjected to experimental TBI, and sensorimotor and cognitive functions were evaluated by rotarod, adhesive tape removal, foot fault, water maze, and passive avoidance tests. Brain tissue loss/neuronal death was examined by MAP2 and NeuN immunostaining, and Cresyl violet staining. White matter injury was assessed by Luxol fast blue staining, and also MBP/SMI32 and Caspr/Nav1.6 immunostaining. Activation of cerebral glial cells and infiltration of blood-borne immune cells were detected by GFAP, Iba-1/CD16/32, Iba-1/CD206, Ly-6B, and F4/80 immunostaining. Brian parenchymal inflammatory cytokines were measured with inflammatory array kits.ResultsGenetic deletion of KLF11 worsened brain trauma-induced sensorimotor and cognitive deficits, brain tissue loss and neuronal death, and white matter injury in mice. KLF11 genetic deficiency in mice also accelerated post-trauma astrocytic activation, promoted microglial polarization to a pro-inflammatory phenotype, and increased the infiltration of peripheral neutrophils and macrophages into the brain parenchyma. Mechanistically, loss-of-KLF11 function was found to directly increase the expression of pro-inflammatory cytokines in the brains of TBI mice.ConclusionKLF11 acts as a novel protective factor in TBI. KLF11 genetic deficiency in mice aggravated the neuroinflammatory responses, grey and white matter injury, and impaired long-term sensorimotor and cognitive recovery. Elucidating the functional importance of KLF11 in TBI may lead us to discover novel pharmacological targets for the development of effective therapies against brain trauma.

Functional outcome at 6 months of surgical traumatic brain injury: A single Caribbean Center pilot study

Background. This is the first prospective study that evaluates the functional outcome after a surgical procedure secondary to a traumatic brain injury, in a single center, in Dominican Republic.Aim. To determine the functional status of surgically treated patients 6 months post-trauma, the relative risk of poor prognosis and association of functional status with the predictive variables of the International Mission for Prognosis and Analysis of Clinical Trials in traumatic brain injury.Materials and methods. A prospective, longitudinal study was conducted in a cohort of 22 patients surgically treated for a traumatic intracranial injury at Dr. Ney Arias Lora Traumatology Hospital in Dominican Republic. We applied the International Mission for Prognosis and Analysis of Clinical Trials calculator, (pupillary response, hemoglobin, hypoxia, age, motor response, computed tomography lesion, hypotension, etc.) prior to surgery and the Extended Glasgow Outcome Scale 6 month after surgery to determine the functional outcome. The International Mission for Prognosis and Analysis of Clinical Trials form was modified by adding preoperative glucocorticosteroids and rehabilitation therapy. The SPSS database (15.0 version, Chicago Il.) was used. Central tendency measures and Fisher's test were applied. Thus, p ≤0.05 with a 95 % confidence interval was considered statistically significant.Results. The predictive variables associated with a poor prognosis were motor response (p = 0.01), hypoxia and hypotension (p = 0.05). Alterations in motor response was associated with increased morbidity and mortality (RR: 10; 95 % CI: 3-22). Normal flexion was found in all patients with good recovery (p = 0.04).Conclusion. As a result, 67 % of patients had a good functional result (moderate disability and good recovery). Mortality was 23 %. Preoperative motor response is a powerful prognostic factor in traumatic brain injury.

Correlative Factors for Traumatic Brain Injury in Combat Ocular Trauma.

Traumatic brain injury (TBI) remains a significant source of disability for active duty service members in both deployed and training settings as well as those who have left active service. Service members with ocular trauma are at risk for a TBI and should be screened appropriately. Early detection results in treatment to minimize long-term sequelae which can often be debilitating. This study is the first to evaluate different combat-related ocular injuries and their associations with TBI. A secondary analysis of existing data was conducted from a prospective study of patients who sustained combat ocular trauma (COT) during Operation Iraqi Freedom (OIF) and Operation Enduring Freedom (OEF) between 2006 and 2020. Clinical data of a total of 88 participants were gathered and each case reviewed, including patient demographics, injury-related factors, history of TBI, and treatments rendered. All cases were then categorized to compare COT (n = 13) versus COT-T (Combat Ocular Trauma associated with TBI; n = 75). The Fisher's exact test was completed for each category to assess for predictive factors of TBI within the ophthalmic trauma cohort. Odds ratios were calculated with their 95% CI. When compared to COT, COT-T was significantly associated with closed globe injuries (56%; OR 4.24, 95% CI 1.08-16.67), blast injuries (89.3%; OR 3.72, 95% CI 0.93-14.9), multiple surgeries (89%; OR 2.51, 95% CI 0.57-11.08), anterior segment injuries (69.3%; OR 1.41, 95% CI 0.42-4.79), optic nerve injuries (24%; OR 1.05, 95% CI 0.26-4.25), orbital fractures (48%; OR 2.08, 95% CI 0.59-7.34), enucleation (17.3%; OR 2.52, 95% CI 0.300-21.08), the use of eye protection (68.6%; OR 2.18, 95% CI 0.57-8.32), and the need to undergo plastic surgery (78.7%; OR 2.30, 95% CI 0.66-8.02). Significant factors associated with COT included penetrating injury (30.8%; OR 0.027, 95% CI 0.07-1.08), posterior segment injuries (92%; OR 0.264, 95% CI 0.032-2.17), bilateral injuries (76.9%; OR 0.678, 95% CI 0.17-2.69), and bilateral blindness (7.7%; OR 0.857, 95% CI 0.092-7.99). Patients who have sustained combat-related ocular injuries, specifically blast injury, anterior segment injury, or an orbital fracture, were noted to be more likely to have also sustained a TBI. However, of the evaluated variables in predicting the co-occurrence of TBI, only closed globe injury was identified as statistically significant. Service members with injuries requiring multiple surgical procedures, reconstructive plastic surgery, or enucleation of an eye were also more likely to be diagnosed with a TBI, but these variables were not found to be predictive of TBI among ocular trauma patients. The presence of eye protection was not protective against TBI. Further studies are needed to find significant predictors of TBI in combat ocular trauma patients to assist in the early and accurate detection of TBI.

Etiology Analysis and Diagnosis and Treatment Strategy of Traumatic Brain Injury Complicated With Hyponatremia.

ObjectiveTo explore the etiology and diagnosis and treatment strategy of traumatic brain injury complicated with hyponatremia.Methods90 patients with traumatic brain injury admitted to our hospital from December 2019 to December 2020 were retrospectively analyzed and divided into hyponatremic group (50 patients) and non-hyponatremic group (40 patients) according to the patients' concomitant hyponatremia, and the clinical data of the two groups were collected and compared. In addition, patients in the hyponatremia group were divided into a control group and an experimental group of 25 patients each according to their order of admission, with the control group receiving conventional treatment and the experimental group using continuous renal replacement therapy (CRRT). Hemodynamic indices, mortality and serum neuron-specific enolase (NSE) indices before and after treatment were compared between the control and experimental groups. The Glasgow coma scale (GCS) was used to assess the degree of coma before and after the treatment in the two groups, and the patients' disease status was assessed using the Acute Physiological and Chronic Health Evaluation Scoring System (APACHE II).ResultsThe etiology of traumatic brain injury complicated with hyponatremia is related to the degree of brain injury, ventricular hemorrhage, cerebral edema, and skull base fracture (P < 0.05). After the treatment, the hemodynamic indexes, APACHE II scores, death rate, and NSE levels of the experimental group were significantly lower than those of the control group (P < 0.001); The experimental group yielded remarkably higher GAC scores as compared to the control group (P < 0.001).ConclusionThe degree of brain injury, ventricular hemorrhage, cerebral edema, and skull base fracture were considered to be the main factors for traumatic brain injury complicated with hyponatremia. Continuous renal replacement therapy can effectively improve the clinical indicators of the patients with a promising curative effect, which merits promotion and application.

Improving Diagnostic Testing Decisions for Pediatric Minor Head Trauma in the Emergency Department: A Two‐Year Prospective Implementation Study

Research ObjectiveThe risk of serious intracranial injury in pediatric patients with minor head trauma (MHT) is less than 5%; most computerized tomography (CT) scans in MHT are normal or contribute little to management, yet expose children to unnecessary radiation. Despite evidence‐based risk classification criteria from the Pediatric Emergency Care Applied Research Network (PECARN) for assessing appropriate CT use during emergency department (ED) visits, barriers persist to replacing unnecessary scans with structured observation. Field readiness assessments at Intermountain Healthcare suggest that physicians often believe they know the risk factors for traumatic brain injury (TBI) but sometimes misremember elements. Information retrieval when delivering ED care can be cumbersome. Many physicians also perceive ordering CT scans is the safest course of action despite a lack of significant symptoms. We theorized that targeting evidence‐based education at the individual scan decision point, coupled with timely performance feedback, would increase cognitive support for assessing risk of clinically‐important TBI (ciTBI), reducing potentially unnecessary scans.Study DesignWe conducted a prospective pre‐post comparison implementation study. The primary implementation strategies were two‐fold. First, we embedded an alert containing an easy‐to‐understand, information‐rich graphic providing current PECARN risk stratification criteria and supporting evidence for classifying ciTBI, along with a risk assessment prompt linked to a CT order. Second, we provided timely feedback on performance and local prompting to educate physicians. Uptake and effectiveness measures included % adherence change in PECARN guidelines and the CT scan rate. Safety was evaluated by counting 48‐hour readmissions with clinical evidence of ciTBI confirmed via chart review. Acceptability, fidelity and feasibility were assessed using qualitative analysis. Statistical analysis was conducted using tests of proportions.Population StudiedApproximately 14,000 pediatric patients presenting with MHT at 22 EDs from January 2019–December 2020 within a single, integrated delivery system including urban, rural and frontier locations and a children's hospital.Principal FindingsYear 1 adherence to PECARN guidelines was 98.7% with a 14% reduction in the CT scan rate for pediatric MHT patients across geographies with no readmissions for ciTBI (Table). Results were sustained in Year 2 despite increased patient acuity in 2020 due to the novel coronavirus pandemic. Subsequent field discussions found good acceptance by physicians noting the alert was relevant, timely and easy to understand. Implementation fidelity was high given routinization of the alert into clinical workflow.ConclusionsCombining local performance feedback with use of an information‐rich text alert was associated with significant improvements in adherence to PECARN guidelines and a reduction in the CT scan order rate for diagnosis of clinically‐important TBI in MHT patients without impacting safety. The routinized nature of the alert was associated with good practice sustainment over multiple years across geographies.Implications for Policy or PracticeSimple, information‐rich text alerts may prove useful as an implementation strategy for updating physicians on changes in evidence‐based triage and risk classification criteria often associated with de‐implementation of legacy clinical practices. Measure Baseline‐Dec2018 Rolling‐6mo Uptake‐Dec2019 Rolling‐12mo Sustainment‐Dec2020 Rolling‐12mo z‐score/p‐value % adherence to PECARN guidelines 95.66% 98.74% 99.32% z = −10.3; p &lt; 0.001 CT scan rate 33% 29% 29% z = 6.0; p &lt; 0.001 48‐hour readmission for ciTBI 0 0 0

Gender Differences in Personal and Situational Risk Factors for Traumatic Brain Injury Among Older Adults.

To investigate differences between older men and women in Taiwan in personal and situational risk factors for sustaining a traumatic brain injury (TBI) versus soft-tissue injury (STI) due to a fall. Matched case-control study. Cases were defined as patients with a primary diagnosis of TBI due to a fall and were identified from those 60 years or older who visited the emergency department (ED) of 3 university-affiliated hospitals in 2015. Matched by the same hospital ED, gender, and time of falling, 3 controls who had no TBI and who had sustained only soft-tissue injury (STI) due to falling were selected for comparison with each case. Personal factors and situational exposures were compared between the control and case groups. In total, 96 cases and 288 controls in men and 72 cases and 216 controls in women participated in this study. Personal factors (sociodemographic and lifestyle factors, medical characteristics, and functional abilities) and situational exposures (location, activities before the fall, center-of-mass change, type of fall, falling direction, protective response, and impact during the fall). In men, after adjusting for other variables, older age (odds ratio [OR] = 1.04), regular alcohol use (OR = 2.03), an indoor fall (OR = 1.92), activity of getting in/out of bed (OR = 2.56), a fall due to dizziness (OR = 4.09), and falling backward (OR = 2.95) were independently associated with a higher odds of TBI. In women, an older age (OR = 1.03), the presence of Parkinson disease (OR = 10.4), activities of toileting (OR = 2.50), getting in/out of bed (OR = 4.90), and negotiating stairs (OR = 7.13), a fall due to dizziness (OR = 5.05), and falling backward (OR = 2.61) were independently associated with a higher odds of TBI. Our results demonstrated similarities and differences in personal and situational risk factors for fall-related TBIs versus STIs between older men and women, and gender differences should be considered when developing intervention strategies.

Fever as an independent prognostic factor in traumatic brain injury

Traumatic Brain Injury (TBI) patients more often than not develop fever within the first few days of their hospitalization. Studies report that causes are variable and according to the pathogenesis, fever may be harmful or protective. The study was conducted to correlate the development of fever with clinical prognosis. Throughout the study spanning 6 months, a total of 98 patients of TBI were included. In the first 48 hours, 54 patients did not develop fever (temperature &gt;37?), 20 patients recorded temperatures between 37? and 39?; and 24 patients developed high fever (39?). On regular temperature monitoring and follow up, it was found that patients developing fever relatively early during hospitalization were more likely to end up with a poor outcome (Glasgow outcome scale 4 to 5). Therefore, fever is independently a predictor of poor prognosis in TBI patients and should be managed diligently in the first few days.

Factors Affecting Traumatic Brain Injury Outcome Among Patients Treated for Head Injury at Surgical Side, in Nekemte Referral Hospital, Oromia, Ethiopia.

Background Traumatic brain injury is an expanding major public health problem and the leading cause of death of the young and productive part of the world’s population. Research is mainly done in high-income countries where only a small proportion of the worldwide fatalities occur. Only few studies have examined prognostic factors of traumatic brain injury outcome in developing countries including Ethiopia. This study was aimed at defining the peculiar demographic and other associated factors of traumatic brain injury (TBI) outcome among patients treated for head injury at Nekemte Referral Hospital. Objective The main purpose of this study was to describe the magnitude of TBI outcome and assess factors associated with unfavourable outcome of TBI among patients treated for head injury at the surgical side in Nekemte Referral Hospital from July 8, 2016 to July 7, 2018. Methods A retrospective cross-sectional document review was conducted among TBI patients treated for head injury from July 8, 2016 to July 7, 2018 at Nekemte Referral Hospital. Data were collected using a pre-tested data collection format. Data analysis was done using SPSS version 20. Descriptive statistics were computed and association between the dependent and independent variables were assessed by using logistic regression. Odds ratios with 95% confidence interval were computed. Significant association was declared when the p value was &lt;0.05. Results In this study, out of 378 cases 95 (25.1%) were discharged with unfavourable outcome of which 37(9.8%) were neurologic deficits and 58 were deaths giving overall mortality rate of 15.3%. Patient age&gt;60years (AOR: 15.13; 95%CI: 3.575-64.028), time interval from injury to treatment (AOR: 16.054; 95%CI: 5.832-44.194), low GCS (AOR: 18.224; 95%CI: 4.167, 79.695), conservative management (AOR: 20.774; 95%CI: 6.106-70.681), pupils abnormality (AOR: 9.078; 95%CI: AOR: 2.996-27.509) were associated with unfavourable outcome. Conclusions A quarter of patients treated for TBI at Nekemte Referral Hospital are discharged with unfavourable outcomes. Old age, delayed presentation to the hospital, low GCS, conservative management, and pupillary abnormality increase the odds of unfavourable outcome. Timely management of TBI before patients develop secondary brain injury and use of surgical intervention based on CT scan diagnosis will reduce the occurrence of unfavourable outcome.

TNF-α-induced p53 activation induces apoptosis in neurological injury.

It was previously confirmed that the apoptotic and necrotic neurons are found during the acute post‐traumatic period, suggesting the induction of apoptosis after traumatic brain injury (TBI). To further explore the involvement of apoptotic factors in TBI, an apoptosis antibody array was conducted to measure the alterations of apoptotic factors in rat brain cortex after TBI. As a result, the Neurological Severity Scale (NSS) scores after TBI were increased, and the cell morphology of the brain cortex was destructed with increased neuronal apoptosis. Furthermore, the caspase‐3 activity was increased, and the apoptotic‐related factors TNF‐α and p53 were up‐regulated in the brain cortex. More importantly, in vitro experiments demonstrated that down‐regulation of TNF‐α in oxygen‐glucose deprivation/reoxygenation (OGD/R) cells increased cell viability and decreased apoptosis and the p53 expression. These results suggested the involvement of TNF‐α–induced apoptotic signalling pathway by activating p53 in the molecular mechanism of neurological injury.

Interleukin-33 (IL-33) as a Diagnostic and Prognostic Factor in Traumatic Brain Injury.

Interleukin-33 (IL-33) is a cytokine involved in interleukin-1 family. Role of IL-33 in immune system activation is well described in the literature. IL-33 has been identified as an endogenous alarm signal (alarmin) to alert various types of immune cells to trauma. In this narrative review, we aimed to underline the diagnostic and prognostic importance of IL-33 in trauma, particularly in brain trauma.

Chitinase-3-Like Protein 1, Serum Amyloid A1, C-Reactive Protein, and Procalcitonin Are Promising Biomarkers for Intracranial Severity Assessment of Traumatic Brain Injury: Relationship with Glasgow Coma Scale and Computed Tomography Volumetry

The volume and location of intracranial hematomas are well-known prognostic factors for traumatic brain injury. The aim of this study was to determine the relationship of serum biomarkers S100β, glial fibrillary acidic protein, neuron-specific enolase, total tau, phosphorylated neurofilament heavy chain, serum amyloid A1 (SAA1), C-reactive protein, procalcitonin (PCT), and chitinase-3-like protein 1 (YKL-40) with traumatic brain injury severity and the amount and location of hemorrhagic traumatic lesions. A prospective observational cohort of 115 patients with a Glasgow Coma Scale (GCS) score of 3-15 were evaluated. Intracranial lesion volume was measured from the semiautomatic segmentation of hematoma on computed tomography using Analyze software. The establishment of possible biomarker cutoff points for intracranial lesion detection was estimated using the Youden Index (J) obtained from the area under the receiver operating characteristic curve. SAA1, YKL-40, PCT, and S100β showed the most robust association with level of consciousness, both with total GCS and motor score. Biomarkers significantly correlated with volumetric measurements of subdural hematoma, traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage, intraventricular hemorrhage, and total amount of bleeding. The type of intracranial hemorrhage was associated with various release patterns of neurobiochemical markers. YKL-40, SAA1, C-reactive protein, and PCT combined with S100β were the most promising biomarkers to determine the presence, location, and extent of traumatic intracranial lesions. Combination of biomarkers further increased the discriminatory capacity for the detection of intracranial bleeding.

Prognostic Predictors of Early Outcomes and Discharge Status of Patients Undergoing Decompressive Craniectomy After Severe Traumatic Brain Injury

Although several prognostic factors for traumatic brain injury (TBI) have been evaluated, a useful predictive scoring model for the outcomes has not been developed for patients with severe TBI who undergo decompressive craniectomy (DC). The aim of the present study was to determine independent predictors and develop a multivariate logistic regression equation to predict the early outcome and discharge status for patients with severe TBI who have undergone DC. A total of 13 different variables were evaluated. The data from all 278 patients with severe TBI who had undergone DC in the present study were retrospectively evaluated from July 2011 to June 2017. Using univariate, multiple logistic regression and prognostic regression scoring equations it was possible to draw receiver operating characteristic curves to predict the early outcomes and discharge status after TBI. We found that younger age (P= 0.012), no significant medical history (P= 0.044), diameter of both pupils <4 mm (P= 0.032), higher admission Glasgow coma scale score (P= 0.004), no tracheotomy (P < 0.001), and DC for severe TBI were associated with a favorable early outcome and discharge status. Using receiver operating characteristic curves to predict the probability of a favorable outcome, the sensitivity was 80.0% and the specificity was 79.5%. Our preliminary findings have shown that 5 variables can be used as independent predictors in assessing the early outcome and discharge status for patients with severe TBI after DC.

Outcome Analysis and Outcome Prognostic Factors of Traumatic Brain Injury in Childhood

Outcome Analysis and Outcome Prognostic Factors of Traumatic Brain Injury in Childhood

Hyponatremia correction causing extrapontine myelinolysis

Rapid correction of hyponatremia will result in extrapontine myelinolysis (EPM). We report a case of 25-year-old male patient who presented with traumatic brain injury (TBI) causing left temporal extradural hematoma (EDH). EDH was managed conservatively. The patient had addiction to alcohol, tobacco smoking, paan (containing betel nuts), and some other addictive substances, details of which were not available. The patient's Glasgow Coma Scale (GCS) and serum sodium were normal at admission. On the 7th and 8th days, serum sodium was 107 and 101 milliequivalent/liter (meq/l), respectively, but GCS was normal. Slow infusion of 3% sodium chloride 100 ml was given on the 7th day and 200 ml on the 8th day. However, serum sodium was raised to 128 meq/l on the 10th day. On the 11th day, GCS was deteriorated and the patient developed quadriparesis. Magnetic resonance imaging (MRI) scan showed bilateral symmetrical basal ganglia T2-weighted hyperintensities suggestive of EPM. In severe hyponatremic patient, it is the rapid rise of serum sodium level which causes EPM. Rapid rise of serum sodium can occur even if hyponatremia was corrected with gradual addition of sodium. Consumption of alcohol and addictive substances contributed along with hyponatremia correction, to the development of EPM. Early detection of hyponatremia is the paramount factor in TBI to prevent the debilitating disease of EPM. MRI plays a crucial role in definite diagnosis of EPM.

Study of fatigue and associated factors in traumatic brain injury and its correlation with insomnia and depression

Introduction:Fatigue has been cited as a common problem associated with traumatic brain injury. A positive association of fatigue has been suggested with insomnia and depression which are also considered to be significantly associated with traumatic brain injury.Aims and Objectives:The present study in post-traumatic brain injury patients is planned to assess the prevalence of fatigue, depression and insomnia, the correlation of fatigue with depression and insomnia and the risk factors associated with fatigue.Material and Methodology:Total 100 patients were recruited in the present study. Interview was focused on assessment of severity of traumatic brain injury, fatigue, insomnia and depression using Glasgow Coma Scale, Fatigue Severity Scale, Insomnia Severity Index and Patients Health Questionnaire(PHQ-9) respectively.Results:Prevalence of depression was found 84% while that of fatigue and insomnia was 50% and 49% respectively. All patients with fatigue had depression whereas those patients without fatigue were also found to have depression (68%) and this correlation was found statistically significant. Similarly, insomnia was reported in 70% of patients who were fatigued against 28% of patients with no fatigue. This was also found statistically significant (P <0.0002).Conclusion:Fatigue in common in post TBI patients. Insomnia and depression are closely associated with fatigue. Clinical and research investigations of fatigue in post-traumatic brain injury should include concomitant screening for treatable depressive symptoms and sleep disorders.

Comparison of two simple models for prediction of short term mortality in patients after severe traumatic brain injury

IntroductionThe subscale motor score of Glasgow Coma Scale (msGCS) and the Abbreviated Injury Score of head region (HAIS) are validated prognostic factors in traumatic brain injury (TBI). The aim was to compare the prognostic performance of a HAIS-based prediction model including HAIS, pupil reactivity and age, and the reference prediction model including msGCS in emergency department (ED), pupil reactivity and age. MethodsSecondary analysis of a prospective epidemiological study including patients after severe TBI (HAIS > 3) with follow-up from the time of accident until 14 days or earlier death was performed in Switzerland. Performance of prediction, based on accuracy of discrimination [area under the receiver-operating curve (AUROC)], calibration (Hosmer-Lemeshow test) and validity (bootstrapping with 2000 repetitions to correct) for optimism of the two prediction models were investigated. A non-inferiority approach was performed and an a priori threshold for important differences was established. ResultsThe cohort included 808 patients [median age 56 {inter-quartile range (IQR) 33–71}, median motor part of GCS in ED 1 (1–6), abnormal pupil reactivity 29.0%] with a death rate of 29.7% at 14 days. The accuracy of discrimination was similar (AUROC HAIS-based prediction model: 0.839; AUROC msGCS-based prediction model: 0.826, difference of the 2 AUROC 0.013 (−0.007 to 0.037). A similar calibration was observed (Hosmer-Lemeshow X2 11.64, p = 0.168 vs. Hosmer-Lemeshow X2 8.66, p = 0.372). Internal validity of HAIS-based prediction model was high (optimism corrected AUROC: 0.837). ConclusionsPerformance of prediction for short-term mortality after severe TBI with HAIS-based prediction model was non-inferior to reference prediction model using msGCS as predictor.